Design Features Associated With Engagement in Mobile Health Physical Activity Interventions Among Youth: Systematic Review of Qualitative and Quantitative Studies.

BACKGROUND: Globally, 81% of youth do not meet the physical activity (PA) guidelines. Youth of families with a low socioeconomic position are less likely to meet the recommended PA guidelines. Mobile health (mHealth) interventions are preferred by youth over traditional in-person approaches and are in line with their media preferences. Despite the promise of mHealth interventions in promoting PA, a common challenge is to engage users in the long term or effectively. Earlier reviews highlighted the association of different design features (eg, notifications and rewards) with engagement among adults. However, little is known about which design features are important for increasing engagement among youth. OBJECTIVE: To inform the design process of future mHealth tools, it is important to investigate the design features that can yield effective user engagement. This systematic review aimed to identify which design features are associated with engagement in mHealth PA interventions among youth who were aged between 4 and 18 years. METHODS: A systematic search was conducted in EBSCOhost (MEDLINE, APA PsycINFO, and Psychology & Behavioral Sciences Collection) and Scopus. Qualitative and quantitative studies were included if they documented design features associated with engagement. Design features and related behavior change techniques and engagement measures were extracted. Study quality was assessed according to the Mixed Method Assessment Tool, and one-third of all screening and data extraction were double coded by a second reviewer. RESULTS: Studies (n=21) showed that various features were associated with engagement, such as a clear interface, rewards, multiplayer game mode, social interaction, variety of challenges with personalized difficulty level, self-monitoring, and variety of customization options among others, including self-set goals, personalized feedback, progress, and a narrative. In contrast, various features need to be carefully considered while designing mHealth PA interventions, such as sounds, competition, instructions, notifications, virtual maps, or self-monitoring, facilitated by manual input. In addition, technical functionality can be considered as a prerequisite for engagement. Research addressing youth from low socioeconomic position families is very limited with regard to engagement in mHealth apps. CONCLUSIONS: Mismatches between different design features in terms of target group, study design, and content translation from behavior change techniques to design features are highlighted and set up in a design guideline and future research agenda. TRIAL REGISTRATION: PROSPERO CRD42021254989; https://tinyurl.com/5n6ppz24.

Just-in-Time Prompts for Running, Walking, and Performing Strength Exercises in the Built Environment: 4-Week Randomized Feasibility Study.

BACKGROUND: App-based mobile health exercise interventions can motivate individuals to engage in more physical activity (PA). According to the Fogg Behavior Model, it is important that the individual receive prompts at the right time to be successfully persuaded into PA. These are referred to as just-in-time (JIT) interventions. The Playful Active Urban Living (PAUL) app is among the first to include 2 types of JIT prompts: JIT adaptive reminder messages to initiate a run or walk and JIT strength exercise prompts during a walk or run (containing location-based instruction videos). This paper reports on the feasibility of the PAUL app and its JIT prompts. OBJECTIVE: The main objective of this study was to examine user experience, app engagement, and users' perceptions and opinions regarding the PAUL app and its JIT prompts and to explore changes in the PA behavior, intrinsic motivation, and the perceived capability of the PA behavior of the participants. METHODS: In total, 2 versions of the closed-beta version of the PAUL app were evaluated: a basic version (Basic PAUL) and a JIT adaptive version (Smart PAUL). Both apps send JIT exercise prompts, but the versions differ in that the Smart PAUL app sends JIT adaptive reminder messages to initiate running or walking behavior, whereas the Basic PAUL app sends reminder messages at randomized times. A total of 23 participants were randomized into 1 of the 2 intervention arms. PA behavior (accelerometer-measured), intrinsic motivation, and the perceived capability of PA behavior were measured before and after the intervention. After the intervention, participants were also asked to complete a questionnaire on user experience, and they were invited for an exit interview to assess user perceptions and opinions of the app in depth. RESULTS: No differences in PA behavior were observed (Z=-1.433; P=.08), but intrinsic motivation for running and walking and for performing strength exercises significantly increased (Z=-3.342; P<.001 and Z=-1.821; P=.04, respectively). Furthermore, participants increased their perceived capability to perform strength exercises (Z=2.231; P=.01) but not to walk or run (Z=-1.221; P=.12). The interviews indicated that the participants were enthusiastic about the strength exercise prompts. These were perceived as personal, fun, and relevant to their health. The reminders were perceived as important initiators for PA, but participants from both app groups explained that the reminder messages were often not sent at times they could exercise. Although the participants were enthusiastic about the functionalities of the app, technical issues resulted in a low user experience. CONCLUSIONS: The preliminary findings suggest that the PAUL apps are promising and innovative interventions for promoting PA. Users perceived the strength exercise prompts as a valuable addition to exercise apps. However, to be a feasible intervention, the app must be more stable.

Evaluating the Impact of Adaptive Personalized Goal Setting on Engagement Levels of Government Staff With a Gamified mHealth Tool: Results From a 2-Month Randomized Controlled Trial.

BACKGROUND: Although the health benefits of physical activity are well established, it remains challenging for people to adopt a more active lifestyle. Mobile health (mHealth) interventions can be effective tools to promote physical activity and reduce sedentary behavior. Promising results have been obtained by using gamification techniques as behavior change strategies, especially when they were tailored toward an individual's preferences and goals; yet, it remains unclear how goals could be personalized to effectively promote health behaviors. OBJECTIVE: In this study, we aim to evaluate the impact of personalized goal setting in the context of gamified mHealth interventions. We hypothesize that interventions suggesting health goals that are tailored based on end users' (self-reported) current and desired capabilities will be more engaging than interventions with generic goals. METHODS: The study was designed as a 2-arm randomized intervention trial. Participants were recruited among staff members of 7 governmental organizations. They participated in an 8-week digital health promotion campaign that was especially designed to promote walks, bike rides, and sports sessions. Using an mHealth app, participants could track their performance on two social leaderboards: a leaderboard displaying the individual scores of participants and a leaderboard displaying the average scores per organizational department. The mHealth app also provided a news feed that showed when other participants had scored points. Points could be collected by performing any of the 6 assigned tasks (eg, walk for at least 2000 m). The level of complexity of 3 of these 6 tasks was updated every 2 weeks by changing either the suggested task intensity or the suggested frequency of the task. The 2 intervention arms-with participants randomly assigned-consisted of a personalized treatment that tailored the complexity parameters based on participants' self-reported capabilities and goals and a control treatment where the complexity parameters were set generically based on national guidelines. Measures were collected from the mHealth app as well as from intake and posttest surveys and analyzed using hierarchical linear models. RESULTS: The results indicated that engagement with the program inevitably dropped over time. However, engagement was higher for participants who had set themselves a goal in the intake survey. The impact of personalization was especially observed for frequency parameters because the personalization of sports session frequency did foster higher engagement levels, especially when participants set a goal to improve their capabilities. In addition, the personalization of suggested ride duration had a positive effect on self-perceived biking performance. CONCLUSIONS: Personalization seems particularly promising for promoting the frequency of physical activity (eg, promoting the number of suggested sports sessions per week), as opposed to the intensity of the physical activity (eg, distance or duration). Replications and variations of our study setup are critical for consolidating and explaining (or refuting) these effects. TRIAL REGISTRATION: ClinicalTrials.gov NCT05264155; https://clinicaltrials.gov/ct2/show/NCT05264155.

Short and Long-Term Innovations on Dietary Behavior Assessment and Coaching: Present Efforts and Vision of the Pride and Prejudice Consortium.

Overweight, obesity and cardiometabolic diseases are major global health concerns. Lifestyle factors, including diet, have been acknowledged to play a key role in the solution of these health risks. However, as shown by numerous studies, and in clinical practice, it is extremely challenging to quantify dietary behaviors as well as influencing them via dietary interventions. As shown by the limited success of 'one-size-fits-all' nutritional campaigns catered to an entire population or subpopulation, the need for more personalized coaching approaches is evident. New technology-based innovations provide opportunities to further improve the accuracy of dietary assessment and develop approaches to coach individuals towards healthier dietary behaviors. Pride & Prejudice (P&P) is a unique multi-disciplinary consortium consisting of researchers in life, nutrition, ICT, design, behavioral and social sciences from all four Dutch Universities of Technology. P&P focuses on the development and integration of innovative technological techniques such as artificial intelligence (AI), machine learning, conversational agents, behavior change theory and personalized coaching to improve current practices and establish lasting dietary behavior change.

Reinforcement Learning to Send Reminders at Right Moments in Smartphone Exercise Application: A Feasibility Study.

Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning (RL) technique has been used in a smartphone exercise application to promote physical activity. This RL model determines the 'right' time to deliver a restricted number of notifications adaptively, with respect to users' temporary context information (i.e., time and calendar). A four-week trial study was conducted to examine the feasibility of our model with real target users. JITAI reminders were sent by the RL model in the fourth week of the intervention, while the participants could only access the app's other functionalities during the first 3 weeks. Eleven target users registered for this study, and the data from 7 participants using the application for 4 weeks and receiving the intervening reminders were analyzed. Not only were the reaction behaviors of users after receiving the reminders analyzed from the application data, but the user experience with the reminders was also explored in a questionnaire and exit interviews. The results show that 83.3% reminders sent at adaptive moments were able to elicit user reaction within 50 min, and 66.7% of physical activities in the intervention week were performed within 5 h of the delivery of a reminder. Our findings indicated the usability of the RL model, while the timing of the moments to deliver reminders can be further improved based on lessons learned.

A Focus Group Study Among Inactive Adults Regarding the Perceptions of a Theory-Based Physical Activity App.

Background: Despite the increasing attention for the positive effects of physical activity (PA), nearly half of the Dutch citizens do not meet the national PA guidelines. A promising method for increasing PA are mobile exercise applications (apps), especially if they are embedded with theoretically supported persuasive strategies (e.g., goal setting and feedback) that align with the needs and wishes of the user. In addition, it is argued that the operationalization of the persuasive strategies could increase the effectiveness of the app, such as the actual content or visualization of feedback. Although much research has been done to examine the preferences for persuasive strategies, little is known about the needs, wishes, and preferences for the design and operationalization of persuasive strategies. Objective: The purpose of this study was to get insight in the needs, wishes, and preferences regarding the practical operationalization of persuasive strategies in a mobile application aimed at promoting PA in healthy inactive adults. Methods: Five semistructured focus groups were performed. During the focus groups, the participants were led into a discussion about the design and operationalization of six predefined theory-based persuasive strategies (e.g., self-monitoring, feedback, goal setting, reminders, rewards, and social support) directed by two moderators. The audio-recorded focus groups were transcribed verbatim and analyzed following the framework approach. Results: Eight men and 17 women between 35 and 55 years (mean age, 49.2) participated in the study. Outcomes demonstrated diverse preferences for implementation types and design characteristics of persuasive strategies in mobile applications. Basic statistics (such as distance, time and calories), positive feedback based on easy-to-achieve goals that relate to health guidelines, and motivating reminders on a relevant moment were preferred. Participants had mixed preferences regarding rewards and a social platform to invite other users to join PA. Conclusions: Findings indicated that in mHealth applications for healthy but inactive adults, persuasive strategies should be designed and implemented in a way that they relate to health guidelines. Moreover, there is a need for an app that can be adapted or can learn based on personal preferences as, for example, preferences with regard to timing of feedback and reminders differed between people.

Preadolescent Students' Engagement With an mHealth Intervention Fostering Social Comparison for Health Behavior Change: Crossover Experimental Study.

BACKGROUND: Contemporary mobile health (mHealth) interventions use various behavior change techniques to promote healthier lifestyles. Social comparison is one of the techniques that is consensually agreed to be effective in engaging the general population in mHealth interventions. However, it is unclear how this strategy can be best used to engage preadolescents. Nevertheless, this strategy has great potential for this target audience, as they are particularly developing their social skills. OBJECTIVE: This study aims to evaluate how social comparison drives preadolescents' engagement with an mHealth app. METHODS: We designed a 12-week crossover experiment in which we studied 3 approaches to implementing behavior change via social comparison. This study was hosted in a school environment to leverage naturally existing social structures among preadolescents. During the experiment, students and teachers used an mHealth tool that awarded points for performing healthy activities. Participants could read their aggregated scores on a leaderboard and compare their performance with others. In particular, these leaderboards were tweaked to implement 3 approaches of the social comparison technique. The first approach focused on intragroup comparison (ie, students and teachers competing against each other to obtain the most points), whereas the other two approaches focused on intergroup comparison (ie, classes of students and their mentoring teachers collaborating to compete against other classes). Additionally, in the third approach, the performance of teachers was highlighted to further increase students' engagement through teachers' natural exemplary function. To obtain our results, we used linear modeling techniques to analyze the dropout rates and engagement levels for the different approaches. In such analyses, we also considered individual participant traits. RESULTS: Our sample included 313 participants-290 students (92.7%) and 23 teachers (7.3%). It was found that student engagement levels dropped over time and declined during holidays. However, students seemed to monitor the intergroup competitions more closely than the intragroup competitions, as they, on average, checked the mHealth app more often when they were engaged in team-based comparisons. Students, on average, performed the most unique activities when they were engaged in the second intergroup setting, perhaps because their teachers were most active in this setting. Moreover, teachers seemed to play an important role in engaging their students, as their relationship with their students influenced the engagement of the students. CONCLUSIONS: When using social comparison to engage preadolescents with an mHealth tool, an intergroup setting, rather than an intragroup competition, motivated them to engage with the app but did not necessarily motivate them to perform more activities. It seems that the number of unique activities that preadolescents perform depends on the activeness of a role model. Moreover, this effect is amplified by preadolescents' perceptions of closeness to that role model.

Unraveling Mobile Health Exercise Interventions for Adults: Scoping Review on the Implementations and Designs of Persuasive Strategies.

BACKGROUND: It is unclear why some physical activity (PA) mobile health (mHealth) interventions successfully promote PA whereas others do not. One possible explanation is the variety in PA mHealth interventions-not only do interventions differ in the selection of persuasive strategies but also the design and implementation of persuasive strategies can vary. However, limited studies have examined the different designs and technical implementations of strategies or explored if they indeed influenced the effectiveness of the intervention. OBJECTIVE: This scoping review sets out to explore the different technical implementations and design characteristics of common and likely most effective persuasive strategies, namely, goal setting, monitoring, reminders, rewards, sharing, and social comparison. Furthermore, this review aims to explore whether previous mHealth studies examined the influence of the different design characteristics and technical operationalizations of common persuasive strategies on the effectiveness of the intervention to persuade the user to engage in PA. METHODS: An unsystematic snowball and gray literature search was performed to identify the literature that evaluated the persuasive strategies in experimental trials (eg, randomized controlled trial, pre-post test). Studies were included if they targeted adults, if they were (partly) delivered by a mobile system, if they reported PA outcomes, if they used an experimental trial, and when they specifically compared the effect of different designs or implementations of persuasive strategies. The study methods, implementations, and designs of persuasive strategies, and the study results were systematically extracted from the literature by the reviewers. RESULTS: A total of 29 experimental trials were identified. We found a heterogeneity in how the strategies are being implemented and designed. Moreover, the findings indicated that the implementation and design of the strategy has an influence on the effectiveness of the PA intervention. For instance, the effectiveness of rewarding was shown to vary between types of rewards; rewarding goal achievement seems to be more effective than rewarding each step taken. Furthermore, studies comparing different ways of goal setting suggested that assigning a goal to users might appear to be more effective than letting the user set their own goal, similar to using adaptively tailored goals as opposed to static generic goals. This study further demonstrates that only a few studies have examined the influence of different technical implementations on PA behavior. CONCLUSIONS: The different implementations and designs of persuasive strategies in mHealth interventions should be critically considered when developing such interventions and before drawing conclusions on the effectiveness of the strategy as a whole. Future efforts are needed to examine which implementations and designs are most effective to improve the translation of theory-based persuasive strategies into practical delivery forms.

Pilot Evaluation of the Impact of Lottery-Based Incentives on Engagement Levels of Male Low SES Vocational Students With an mHealth App.

In general, individuals with lower socioeconomic status (SES) are less physically active and adhere to poorer diets than higher SES individuals. To promote healthier lifestyles in lower SES populations, we hosted a digital health promotion program among male vocational students at a school in The Netherlands. In a pilot study, we evaluated whether this target audience could be engaged with an mHealth app using lottery-based incentives that trigger feelings of anticipated regret. Especially, we studied the social and interpersonal aspects of regret lotteries in a within-subject experimental design. In this design, subjects either participated in a social variant (i.e., with students competing against their peers for a chance at a regret lottery), or an individual variant (i.e., with subjects solely individually engaged in a lottery). Additionally, we studied the impact of different payout schedules in a between-subject experimental design. In this design, participants were assigned to either a short-term, low-value payout schedule, or a long-term, high-value payout schedule. From a population of 72 male students, only half voluntarily participated in our 10-week program. From interviews, we learned that the main reason for neglecting the program was not related to the lottery-based incentives, nor to the prizes that were awarded. Instead, non-enrolled subjects did not join the program, because their peers were not joining. Paradoxically, it was suggested that students withheld their active participation until a larger portion of the sample was actively participating. From the subjects that enrolled in the program (N = 36, males, between 15 and 25 years of age), we found that a large proportion stopped interacting with the program over time (e.g., after roughly 4 weeks). Our results also indicated that students performed significantly more health-related activities when assigned to the social regret lottery, as opposed to the individual variant. This result was supported by interview responses from active participants: They mainly participated to compete against their peers, and not so much for the prizes. Hence, from this study, we obtained initial evidence on the impact of social and competitive aspects in lottery-based incentives to stimulate engagement levels in lower SES students with an mHealth app.

The Design and Development of a Personalized Leisure Time Physical Activity Application Based on Behavior Change Theories, End-User Perceptions, and Principles From Empirical Data Mining.

Introduction: Many adults do not reach the recommended physical activity (PA) guidelines, which can lead to serious health problems. A promising method to increase PA is the use of smartphone PA applications. However, despite the development and evaluation of multiple PA apps, it remains unclear how to develop and design engaging and effective PA apps. Furthermore, little is known on ways to harness the potential of artificial intelligence for developing personalized apps. In this paper, we describe the design and development of the Playful data-driven Active Urban Living (PAUL): a personalized PA application. Methods: The two-phased development process of the PAUL apps rests on principles from the behavior change model; the Integrate, Design, Assess, and Share (IDEAS) framework; and the behavioral intervention technology (BIT) model. During the first phase, we explored whether location-specific information on performing PA in the built environment is an enhancement to a PA app. During the second phase, the other modules of the app were developed. To this end, we first build the theoretical foundation for the PAUL intervention by performing a literature study. Next, a focus group study was performed to translate the theoretical foundations and the needs and wishes in a set of user requirements. Since the participants indicated the need for reminders at a for-them-relevant moment, we developed a self-learning module for the timing of the reminders. To initialize this module, a data-mining study was performed with historical running data to determine good situations for running. Results: The results of these studies informed the design of a personalized mobile health (mHealth) application for running, walking, and performing strength exercises. The app is implemented as a set of modules based on the persuasive strategies "monitoring of behavior," "feedback," "goal setting," "reminders," "rewards," and "providing instruction." An architecture was set up consisting of a smartphone app for the user, a back-end server for storage and adaptivity, and a research portal to provide access to the research team. Conclusions: The interdisciplinary research encompassing psychology, human movement sciences, computer science, and artificial intelligence has led to a theoretically and empirically driven leisure time PA application. In the current phase, the feasibility of the PAUL app is being assessed.

Which Game Narratives Do Adolescents of Different Gameplay and Sociodemographic Backgrounds Prefer? A Mixed-Methods Analysis.

Objective: The aim of this study was to investigate which narrative elements of digital game narratives are preferred by the general adolescent population, and to examine associations with gender, socioeconomic status (SES), and gameplay frequency. Further, the study aims to discuss how results can be translated to serious digital games. Materials and Methods: Adolescents were recruited through school to complete a survey on narrative preferences in digital games. The survey included questions on sociodemographic information, frequency of gameplay, and an open-ended question on what could be an appealing narrative for them. Data were analyzed in a mixed-methods approach, using thematic analysis and chi-square analyses to determine narrative preferences and the associations between game narrative elements and player characteristics (gender, SES, and frequency of gameplay). Results: The sample consisted of 446 adolescents (12-15 years old) who described 30 narrative subthemes. Preferences included human characters as protagonists; nonhuman characters only as antagonists; realistic settings, such as public places or cities; and a strong conflict surrounding crime, catastrophe, or war. Girls more often than boys defined characters by their age, included avatars, located the narrative in private places, developed profession-related skills, and included a positive atmosphere. Adolescents of nonacademic education more often than adolescents of academic education defined characters by criminal actions. Infrequent players more often included human characters defined by their age than frequent players. After performing a Bonferroni correction, narrative preferences for several gender differences remained. Conclusion: Different narrative elements related to subgroups of adolescents by gender, SES, and frequency of gameplay. Customization of narratives in serious digital health games should be warranted for boys and girls; yet, further research is needed to specify how to address girls in particular.

Evaluation of the impact of extrinsic rewards on user engagement in a health promotion context.

Despite the many mHealth solutions available, it remains unclear what their success factors are. Specifically, there has been controversy on the effectiveness of extrinsic rewards. This study evaluates two design elements of an mHealth solution - i.e., social proof and tangible rewards - and their impact on user engagement. During a four-week campaign, a sample of 143 university staff members engaged in a health promotion campaign. Participants were randomly distributed over one of three treatment groups. It was found that the introduction of a sufficiently meaningful, unexpected, and customized extrinsic reward can engage participants significantly more in a health promotion context.

The Effect of Physical Activity Interventions Comprising Wearables and Smartphone Applications on Physical Activity: a Systematic Review and Meta-analysis.

BACKGROUND: Worldwide physical activity levels of adults are declining, which is associated with increased chronic disease risk. Wearables and smartphone applications offer new opportunities to change physical activity behaviour. This systematic review summarizes the evidence regarding the effect of wearables and smartphone applications on promoting physical activity. METHODS: PubMed, EMBASE and Cochrane databases were searched for RCTs, published since January 2008, on wearables and smartphone applications to promote physical activity. Studies were excluded when the study population consisted of children or adolescents, the intervention did not promote physical activity or comprised a minor part of the intervention, or the intervention was Internet-based and not accessible by smartphone. Risk of bias was assessed by the Cochrane collaboration tool. The primary outcome was changed in physical activity level. Meta-analyses were performed to assess the pooled effect on (moderate-to-vigorous) physical activity in minutes per day and daily step count. RESULTS: Eighteen RCTs were included. Use of wearables and smartphone applications led to a small to moderate increase in physical activity in minutes per day (SMD = 0.43, 95% CI = 0.03 to 0.82; I2 = 85%) and a moderate increase in daily step count (SMD = 0.51, 95% CI = 0.12 to 0.91; I2 = 90%). When removing studies with an unclear or high risk of bias, intervention effects improved and statistical heterogeneity was removed. CONCLUSIONS: This meta-analysis showed a small to moderate effect of physical activity interventions comprising wearables and smartphone applications on physical activity. Hence, wearables and smartphone applications are likely to bring new opportunities in delivering tailored interventions to increase levels of physical activity.

Games for Health for Children-Current Status and Needed Research.

Videogames for health (G4H) offer exciting, innovative, potentially highly effective methods for increasing knowledge, delivering persuasive messages, changing behaviors, and influencing health outcomes. Although early outcome results are promising, additional research is needed to determine the game design and behavior change procedures that best promote G4H effectiveness and to identify and minimize possible adverse effects. Guidelines for ideal use of different types of G4H by children and adolescents should be elucidated to enhance effectiveness and minimize adverse effects. G4H stakeholders include organizational implementers, policy makers, players and their families, researchers, designers, retailers, and publishers. All stakeholders should be involved in G4H development and have a voice in setting goals to capitalize on their insights to enhance effectiveness and use of the game. In the future, multiple targeted G4H should be available to meet a population's diverse health needs in developmentally appropriate ways. Substantial, consistent, and sophisticated research with appropriate levels of funding is needed to realize the benefits of G4H.

Replacing Non-Active Video Gaming by Active Video Gaming to Prevent Excessive Weight Gain in Adolescents.

OBJECTIVE: The aim of the current study was to evaluate the effects of and adherence to an active video game promotion intervention on anthropometrics, sedentary screen time and consumption of sugar-sweetened beverages and snacks among non-active video gaming adolescents who primarily were of healthy weight. METHODS: We assigned 270 gaming (i.e. ≥ 2 hours/week non-active video game time) adolescents randomly to an intervention group (n = 140) (receiving active video games and encouragement to play) or a waiting-list control group (n = 130). BMI-SDS (SDS = adjusted for mean standard deviation score), waist circumference-SDS, hip circumference and sum of skinfolds were measured at baseline, at four and ten months follow-up (primary outcomes). Sedentary screen time, physical activity, consumption of sugar-sweetened beverages and snacks, and process measures (not at baseline) were assessed with self-reports at baseline, one, four and ten months follow-up. Multi-level-intention to treat-regression analyses were conducted. RESULTS: The control group decreased significantly more than the intervention group on BMI-SDS (ß = 0.074, 95%CI: 0.008;0.14), and sum of skinfolds (ß = 3.22, 95%CI: 0.27;6.17) (overall effects). The intervention group had a significantly higher decrease in self-reported non-active video game time (ß = -1.76, 95%CI: -3.20;-0.32) and total sedentary screen time (Exp (ß = 0.81, 95%CI: 0.74;0.88) than the control group (overall effects). The process evaluation showed that 14% of the adolescents played the Move video games every week ≥ 1 hour/week during the whole intervention period. CONCLUSIONS: The active video game intervention did not result in lower values on anthropometrics in a group of 'excessive' non-active video gamers (mean ~ 14 hours/week) who primarily were of healthy weight compared to a control group throughout a ten-month-period. Even some effects in the unexpected direction were found, with the control group showing lower BMI-SDS and skin folds than the intervention group. The intervention did result in less self-reported sedentary screen time, although these results are likely biased by social desirability. TRIAL REGISTRATION: Dutch Trial Register NTR3228.

Efficient and Effective Change Principles in Active Videogames.

Active videogames have the potential to enhance population levels of physical activity but have not been successful in achieving this aim to date. This article considers a range of principles that may be important to the design of effective and efficient active videogames from diverse discipline areas, including behavioral sciences (health behavior change, motor learning, and serious games), business production (marketing and sales), and technology engineering and design (human-computer interaction/ergonomics and flow). Both direct and indirect pathways to impact on population levels of habitual physical activity are proposed, along with the concept of a game use lifecycle. Examples of current active and sedentary electronic games are used to understand how such principles may be applied. Furthermore, limitations of the current usage of theoretical principles are discussed. A suggested list of principles for best practice in active videogame design is proposed along with suggested research ideas to inform practice to enhance physical activity.

Associations between active video gaming and other energy-balance related behaviours in adolescents: a 24-hour recall diary study.

BACKGROUND: Active video games may contribute to reducing time spent in sedentary activities, increasing physical activity and preventing excessive weight gain in adolescents. Active video gaming can, however, only be beneficial for weight management when it replaces sedentary activities and not other physical activity, and when it is not associated with a higher energy intake. The current study therefore examines the association between active video gaming and other energy-balance-related behaviours (EBRBs). FINDINGS: Adolescents (12-16 years) with access to an active video game and who reported to spend at least one hour per week in active video gaming were invited to participate in the study. They were asked to complete electronic 24-hour recall diaries on five randomly assigned weekdays and two randomly assigned weekend-days in a one-month period, reporting on time spent playing active and non-active video games and on other EBRBs. Findings indicated that adolescents who reported playing active video games on assessed days also reported spending more time playing non-active video games (Median = 23.6, IQR = 56.8 minutes per week) compared to adolescents who did not report playing active video games on assessed days (Median = 10.0, IQR = 51.3 minutes per week, P < 0.001 (Mann Whitney test)). No differences between these groups were found in other EBRBs. Among those who played active video games on assessed days, active video game time was positively yet weakly associated with TV/DVD time and snack consumption. Active video game time was not significantly associated with other activities and sugar-sweetened beverages intake. CONCLUSIONS: The results suggest that it is unlikely that time spent by adolescents in playing active video games replaces time spent in other physically active behaviours or sedentary activities. Spending more time playing active video games does seem to be associated with a small, but significant increase in intake of snacks. This suggests that interventions aimed at increasing time spent on active video gaming, may have unexpected side effects, thus warranting caution.

Active video games as a tool to prevent excessive weight gain in adolescents: rationale, design and methods of a randomized controlled trial.

BACKGROUND: Excessive body weight, low physical activity and excessive sedentary time in youth are major public health concerns. A new generation of video games, the ones that require physical activity to play the games--i.e. active games--may be a promising alternative to traditional non-active games to promote physical activity and reduce sedentary behaviors in youth. The aim of this manuscript is to describe the design of a study evaluating the effects of a family oriented active game intervention, incorporating several motivational elements, on anthropometrics and health behaviors in adolescents. METHODS/DESIGN: The study is a randomized controlled trial (RCT), with non-active gaming adolescents aged 12-16 years old randomly allocated to a ten month intervention (receiving active games, as well as an encouragement to play) or a waiting-list control group (receiving active games after the intervention period). Primary outcomes are adolescents' measured BMI-SDS (SDS=adjusted for mean standard deviation score), waist circumference-SDS, hip circumference and sum of skinfolds. Secondary outcomes are adolescents' self-reported time spent playing active and non-active games, other sedentary activities and consumption of sugar-sweetened beverages. In addition, a process evaluation is conducted, assessing the sustainability of the active games, enjoyment, perceived competence, perceived barriers for active game play, game context, injuries from active game play, activity replacement and intention to continue playing the active games. DISCUSSION: This is the first adequately powered RCT including normal weight adolescents, evaluating a reasonably long period of provision of and exposure to active games. Next, strong elements are the incorporating motivational elements for active game play and a comprehensive process evaluation. This trial will provide evidence regarding the potential contribution of active games in prevention of excessive weight gain in adolescents. TRIAL REGISTRATION: Dutch Trial register NTR3228.

Active and non-active video gaming among Dutch adolescents: who plays and how much?

OBJECTIVES: The aim of study was to determine prevalence and identify demographic correlates of active and non-active gaming among adolescents. DESIGN: Cross-sectional. METHODS: A survey, assessing game behavior and correlates, was conducted among adolescents (12-16 years, n = 373), recruited via schools. Multivariable logistic regression analyses were conducted to examine demographic correlates of active gaming (≥ 1 h per week) and non-active gaming (>7h per week). RESULTS: Of all participants (n=373), 3% reported to play exclusively active games, 40% active games and non-active games, 40% exclusively non-active games, and 17% not playing video games at all. Active gaming adolescents played active games on average on 1.5 (sd = 1.2) days per school week for 36 (sd = 32.9)min and 1 (sd = 0.54) day per weekend for 42 (sd = 36.5)min. Non-active gaming adolescents played on average on 3.3 (sd = 1.6) days per school week for 65 (sd = 46.0)min and 1.4 (sd = 0.65) days per weekend for 80 (sd = 50.8)min. Adolescents attending lower levels of education were more likely to play active games ≥ 1 h per week than adolescents attending higher educational levels. Boys and older adolescents were more likely to play non-active games >7h per week, than girls or younger adolescents. CONCLUSIONS: Many adolescents play active games, especially those following a lower educational level, but time spent in this activity is relatively low compared to non-active gaming. To be feasible as a public health strategy, active gaming interventions should achieve more time is spent on active gaming at the expense of non-active gaming.

Dutch children and parents' views on active and non-active video gaming.

Active video games that require whole body movement to play the game may be an innovative health promotion tool to substitute sedentary pastime with more active time and may therefore contribute to children's health. To inform strategies aimed at reducing sedentary behavior by replacing non-active by active gaming, opinions about active and non-active video games are explored among 8- to 12-year-old children and their parents. Six qualitative, semi-structured focus groups were held with 8- to 12-year-old children (n = 46) and four with their parents (n = 19) at three different primary schools in The Netherlands. The focus groups with children discussed game preferences, gaming context and perceived game-related parenting. The focus groups with parents addressed considerations in purchasing video games, perceived positive and negative consequences of gaming, and game-related parenting. Both children and their parents were very positive about active video games and preferred active games over non-active games. Active video games were considered more social than non-active video games, and active games were played more often together with friends and family than non-active video games. Parenting practices did not differ for active and non-active video games, although some parents were less strict regarding active games. Two conditions for practical implementation were met: children enjoyed active video games, and parents were willing to buy active video games. Active video games were preferred to non-active video games, illustrating that using active video games is a promising health promotion tool to reduce sedentary pastime in youth.