Engagement analysis of a persuasive-design-optimized eHealth intervention through machine learning.

The challenge of sustaining user engagement in eHealth interventions is a pressing issue with significant implications for the effectiveness of these digital health tools. This study investigates user engagement in a cognitive-behavioral therapy-based eHealth intervention for procrastination, using a dataset from a randomized controlled trial of 233 university students. Various machine learning models, including Decision Tree, Gradient Boosting, Logistic Regression, Random Forest, and Support Vector Machines, were employed to predict patterns of user engagement. The study adopted a two-phase analytical approach. In the first phase, all features of the dataset were included, revealing 'total_minutes'-the total time participants spent on the intervention and the eHealth platform-as the most significant predictor of engagement. This finding emphasizes the intuitive notion that early time spent on the platform and the intervention is a strong indicator of later user engagement. However, to gain a deeper understanding of engagement beyond this predominant metric, the second phase of the analysis excluded 'total_minutes'. This approach allowed for the exploration of the roles and interdependencies of other engagement indicators, such as 'number_intervention_answersheets'-the number of completed lessons, 'logins_first_4_weeks'-login frequency, and 'number_diary_answersheets'-the number of completed diaries. The results from this phase highlighted the multifaceted nature of engagement, showing that while 'total_minutes' is strongly correlated with engagement, indicating that more engaged participants tend to spend more time on the intervention, the comprehensive engagement profile also depends on additional aspects like lesson completions and frequency of platform interactions.

Impact of an Online Discussion Forum on Self-Guided Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Randomized Trial.

BACKGROUND: Internet-delivered cognitive behavioral therapy (ICBT) is an effective and accessible treatment for various mental health concerns. ICBT has shown promising treatment outcomes among public safety personnel (PSP), who experience high rates of mental health problems and face barriers to accessing other mental health services. Client engagement and clinical outcomes are better in ICBT with therapist guidance, but ICBT is easier to implement on a large scale when it is self-guided. Therefore, it is important to identify strategies to improve outcomes and engagement in self-guided ICBT and other self-guided digital mental health interventions. One such strategy is the use of online discussion forums to provide ICBT clients with opportunities for mutual social support. Self-guided interventions accompanied by online discussion forums have shown excellent treatment outcomes, but there is a need for research experimentally testing the impact of online discussion forums in ICBT. OBJECTIVE: We aimed to evaluate a transdiagnostic, self-guided ICBT intervention tailored specifically for PSP (which had not previously been assessed), assess the impact of adding a therapist-moderated online discussion forum on outcomes, and analyze participants' feedback to inform future research and implementation efforts. METHODS: In this randomized trial, we randomly assigned participating PSP (N=107) to access an 8-week transdiagnostic, self-guided ICBT course with or without a built-in online discussion forum. Enrollment and participation were entirely web-based. We assessed changes in depression, anxiety, and posttraumatic stress as well as several secondary outcome measures (eg, treatment engagement and satisfaction) using questionnaires at the pre-enrollment, 8-week postenrollment, and 20-week postenrollment time points. Mixed methods analyses included multilevel modeling and qualitative content analysis. RESULTS: Participants engaged minimally with the forum, creating 9 posts. There were no differences in treatment outcomes between participants who were randomly assigned to access the forum (56/107, 52.3%) and those who were not (51/107, 47.7%). Across conditions, participants who reported clinically significant symptoms during enrollment showed large and statistically significant reductions in symptoms (P<.05 and d>0.97 in all cases). Participants also showed good treatment engagement and satisfaction, with 43% (46/107) of participants fully completing the intervention during the course of the study and 96% (79/82) indicating that the intervention was worth their time. CONCLUSIONS: Previous research has shown excellent clinical outcomes for self-guided ICBT accompanied by discussion forums and good engagement with those forums. Although clinical outcomes in our study were excellent across conditions, engagement with the forum was poor, in contrast to previous research. We discuss several possible interpretations of this finding (eg, related to the population under study or the design of the forum). Our findings highlight a need for more research evaluating the impact of online discussion forums and other strategies for improving outcomes and engagement in self-guided ICBT and other digital mental health interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05145582; https://clinicaltrials.gov/study/NCT05145582.

Exploring the Use of Persuasive System Design Principles to Enhance Medication Incident Reporting and Learning Systems: Scoping Reviews and Persuasive Design Assessment.

BACKGROUND: Medication incidents (MIs) causing harm to patients have far-reaching consequences for patients, pharmacists, public health, business practice, and governance policy. Medication Incident Reporting and Learning Systems (MIRLS) have been implemented to mitigate such incidents and promote continuous quality improvement in community pharmacies in Canada. They aim to collect and analyze MIs for the implementation of incident preventive strategies to increase safety in community pharmacy practice. However, this goal remains inhibited owing to the persistent barriers that pharmacies face when using these systems. OBJECTIVE: This study aims to investigate the harms caused by medication incidents and technological barriers to reporting and identify opportunities to incorporate persuasive design strategies in MIRLS to motivate reporting. METHODS: We conducted 2 scoping reviews to provide insights on the relationship between medication errors and patient harm and the information system-based barriers militating against reporting. Seven databases were searched in each scoping review, including PubMed, Public Health Database, ProQuest, Scopus, ACM Library, Global Health, and Google Scholar. Next, we analyzed one of the most widely used MIRLS in Canada using the Persuasive System Design (PSD) taxonomy-a framework for analyzing, designing, and evaluating persuasive systems. This framework applies behavioral theories from social psychology in the design of technology-based systems to motivate behavior change. Independent assessors familiar with MIRLS reported the degree of persuasion built into the system using the 4 categories of PSD strategies: primary task, dialogue, social, and credibility support. RESULTS: Overall, 17 articles were included in the first scoping review, and 1 article was included in the second scoping review. In the first review, significant or serious harm was the most frequent harm (11/17, 65%), followed by death or fatal harm (7/17, 41%). In the second review, the authors found that iterative design could improve the usability of an MIRLS; however, data security and validation of reports remained an issue to be addressed. Regarding the MIRLS that we assessed, participants considered most of the primary task, dialogue, and credibility support strategies in the PSD taxonomy as important and useful; however, they were not comfortable with some of the social strategies such as cooperation. We found that the assessed system supported a number of persuasive strategies from the PSD taxonomy; however, we identified additional strategies such as tunneling, simulation, suggestion, praise, reward, reminder, authority, and verifiability that could further enhance the perceived persuasiveness and value of the system. CONCLUSIONS: MIRLS, equipped with persuasive features, can become powerful motivational tools to promote safer medication practices in community pharmacies. They have the potential to highlight the value of MI reporting and increase the readiness of pharmacists to report incidents. The proposed persuasive design guidelines can help system developers and community pharmacy managers realize more effective MIRLS.

Exploring the usability of an internet-based intervention and its providing eHealth platform in an eye-tracking study.

The proliferation of online eHealth has made it much easier for users to access healthcare services and interventions from the comfort of their own homes. This study looks at how well one such platform-eSano-performs in terms of user experience when delivering mindfulness interventions. In order to assess usability and user experience, several tools such as eye-tracking technology, think-aloud sessions, a system usability scale questionnaire, an application questionnaire, and post-experiment interviews were employed. Participants were evaluated while they accessed the first module of the mindfulness intervention provided by eSano to measure their interaction with the app, and their level of engagement, and to obtain feedback on both the intervention and its overall usability. The results revealed that although users generally rated their experience with the app positively in terms of overall satisfaction, according to data collected through the system usability scale questionnaire, participants rated the first module of the mindfulness intervention as below average. Additionally, eye-tracking data showed that some users skipped long text blocks in favor of answering questions quickly while others spent more than half their time reading them. Henceforth, recommendations were put forward to improve both the usability and persuasiveness of the app-such as incorporating shorter text blocks and more engaging interactive elements-in order to raise adherence rates. Overall findings from this study provide valuable insights into how users interact with the eSano's participant app which can be used as guidelines for the future development of more effective and user-friendly platforms. Moreover, considering these potential improvements will help foster more positive experiences that promote regular engagement with these types of apps; taking into account emotional states and needs that vary across different age groups and abilities. Supplementary Information: The online version contains supplementary material available at 10.1007/s12652-023-04635-4.

Designing a Persuasive E-Coaching Application for Informal Caregivers.

Being an informal caregiver is not easy, and might cause physical and psychosocial burden, especially in the long run. However, the formal health care system has little support for informal caregivers who experience abandonment and lack information. Mobile health can potentially be an efficient and cost-effective way of supporting informal caregivers. However, research has shown that mHealth systems often have problems with usability, and people do not use the systems for more than a short period. Therefore, this paper explores the design of an mHealth app using Persuasive Design, an established design framework. This paper presents the design of the first version of the e-coaching application using the persuasive design framework and unmet needs of informal caregivers from the literature. This prototype version will be updated based on interview data from informal caregivers in Sweden.

COVID Alert: Factors Influencing the Adoption of Exposure Notification Apps Among Canadian Residents.

The continued emergence of new variants of COVID-19 such as the Delta and Omicron variants, which can cause breakthrough infections, indicates that contact tracing and exposure notification apps (ENAs) will continue to be useful for the long haul. However, there is limited work to uncover the strongest factors that influence their adoption. Using Canada's "COVID Alert" as a case study, we conducted an empirical, technology-acceptance study to investigate the key factors that account for users' intention to use ENAs and the moderating effect of important human and design factors. Our path model analysis shows that four factors significantly influence the adoption of COVID Alert among Canadian residents: perceived risk, perceived usefulness, perceived trust, and perceived compatibility. The overall model explains over 60% of intention to use, with type of design, use case (functional interface), and adoption status moderating the strength of the relationships between the four factors and intention to use. We discuss these findings and make recommendations for the design of future ENAs.

A new perspective of aroma face mask on COVID-19 pandemic.

In times of the COVID-19 pandemic, wearing face masks is strongly recommended as a public health measure to stop the spread of the Sars Coronavirus. However, there are still people who ignore using this effective protective tool due to the lack of comfortable face masks on the market. Therefore, in the current study, we assessed commercially available face masks namely N95 masks, surgical masks, and cloth masks in order to find out their weakness. In addition, the identification needs of people from a face mask were collected by an online questionnaire. According to the information obtained; we achieved key factors required to design a new type of face mask using the Computer-Aided Design (CAD) and the final design was printed. Moreover, the long-term use of herbs in Iranian Traditional Medicine persuaded us to add a humidifier containing aromatic plants essential oils such as Eucalyptus globules Labill. and Rosa damascene Mill. with scientifically proven health benefits such as pain reliever, relaxing properties and antimicrobial activities. We are expected that these aromas would be an effective way to eliminate the problems of individuals suffering from air pollutants, respiratory disorders, and COVID which leads to encouraging more people to use face masks during pandemics or air pollution.

Need for Cognition Among Users of Self-Monitoring Systems for Physical Activity: Survey Study.

BACKGROUND: Need for cognition (NFC) is among the most studied personality traits in psychology. Despite its apparent relevance for engaging with technology and the use of information, it has not been studied in the context of self-monitoring systems and wearables for health. This study is the first to explore the relationship between NFC and commercial self-monitoring systems among healthy users. OBJECTIVE: This study aims to explore the effect of NFC levels on the selection of self-monitoring systems and evaluation of system features of self-monitoring and feedback, as well as perceived credibility and perceived persuasiveness. We also assessed perceived behavior change in the form of self-reported activity after adopting the system. METHODS: Survey data were collected in October 2019 among university students and personnel. The invitation to respond to the questionnaire was addressed to those who had used a digital system to monitor their physical activity for at least two months. The web-based questionnaire comprised the following 3 parts: details of system use, partially randomly ordered theoretical measurement items, and user demographics. The data were analyzed using structural equation modeling. The effect of NFC was assessed both as 3 groups (low, moderate, and high) and as a continuous moderator variable. RESULTS: In all, 238 valid responses to the questionnaire were obtained. Individuals with high NFC reported all tested system features with statistically significantly higher scores. The NFC also had some effect on system selection. Hypothesized relationships with perceived credibility gained support in a different way for individuals with low and high NFC; for those with low NFC, credibility increased the persuasiveness of the system, but this effect was absent among individuals with high NFC. For users with high NFC, credibility was related to feedback and self-monitoring and perhaps continuously evaluated during prolonged use instead of being a static system property. Furthermore, the relationship between perceived persuasiveness and self-reported activity after adopting the system had a large effect size (Cohen f2=0.355) for individuals with high NFC, a small effect size for individuals with moderate NFC (Cohen f2=0.107), and a nonsignificant path (P=.16) for those with low NFC. We also detected a moderating effect of NFC in two paths on perceived persuasiveness but only among women. Our research model explained 59.2%, 63.9%, and 47.3% of the variance in perceived persuasiveness of the system among individuals with low, moderate, and high NFC, respectively. CONCLUSIONS: The system choices of individuals seem to reflect their intrinsic motivations to engage with rich data, and commercial systems might themselves be a tailoring strategy. Important characteristics of the system, such as perceived credibility, have different roles depending on the NFC levels. Our data demonstrate that NFC as a trait that differentiates information processing has several implications for the selection, design, and tailoring of self-monitoring systems.

A model of integrated remote monitoring and behaviour change for osteoarthritis.

BACKGROUND: The National Institute for Health and Care Excellence recommends the use of digital and mobile health technologies to facilitate behaviour change interventions. Due to its high prevalence and dependence upon patient self-management strategies, osteoarthritis is one musculoskeletal condition which may benefit from such approaches. This is particularly pertinent due to the increasing use of remote monitoring technologies to collect patient data and facilitate self-management in individuals outside of hospital clinics. In practice however, application of digital behaviour change interventions is difficult due to insufficient reporting of behaviour change theories in the current literature. When digital technologies are employed to alter behaviour change in osteoarthritis, they often focus on physical activity. Currently, such interventions focus of self-efficacy but do not often explicitly report the behaviour change techniques they use to facilitate these changes. METHODS: This paper proposes a new model of integrating specific behaviour change principles (persuasive design) in an integrated model of remote monitoring and digital behaviour change interventions for osteoarthritis. RESULTS: There is potential to combine remote monitoring systems of patient data through digital and mobile technologies with behaviour change principles to improve physical activity behaviours in individuals with osteoarthritis. The use of persuasive design principles (e.g. prompts or nudges) through mobile notifications and strategic system design can be directed to enhance behaviour change. A validated measure of behaviour change, such as the patient activation measure, will allow effective evaluation of such systems. CONCLUSIONS: Digital behaviour change interventions should be directed towards the underlying principles of behaviour change they employ, although this is not commonly reported in practice. Such interventions can be integrated within remote monitoring pathways using persuasive design techniques to enhance patient activation. This approach can enhance self-management in individuals with musculoskeletal conditions, such as osteoarthritis.

Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression.

BACKGROUND: Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT. OBJECTIVE: This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety. METHODS: We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design. RESULTS: Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17). CONCLUSIONS: These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT.

Effort-Optimized Intervention Model: Framework for Building and Analyzing Digital Interventions That Require Minimal Effort for Health-Related Gains.

The majority of digital health interventions lean on the promise of bringing health and self-care into people's homes and hands. However, these interventions are delivered while people are in their triggering environments, which places competing demands on their attention. Individuals struggling to change or learn a new behavior have to work hard to achieve even a minor change because of the automatic forces propelling them back to their habitual behaviors. We posit that effort and burden should be explored at the outset and throughout the digital intervention development process as a core therapeutic mechanism, beyond the context of design or user experience testing. In effort-focused conceptualization, it is assumed that, even though goals are rational and people want to achieve them, they are overtaken by competing cognitive, emotional, and environmental processes. We offer the term effort-optimized intervention to describe interventions that focus on user engagement in the face of competing demands. We describe design components based on a 3-step process for planning an effort-optimized intervention: (1) nurturing effortless cognitive and environmental salience to help people keep effort-related goals prominent despite competition; (2) making it as effortless as possible to complete therapeutic activities to avoid ego depletion and self-efficacy reduction; and (3) turning the necessary effortful activities into sustainable assets. We conclude by presenting an example of designing a digital health intervention based on the effort-optimized intervention model.

A Preliminary Evaluation of Mobile Phone Apps to Curb Alcohol Consumption.

Mobile apps have become increasingly prevalent in modern society, and persuasive technology has a broader market than ever. Mobile-based alcohol cessation apps can promote positive behaviour change in users and improve the overall health of our society. This research aimed to understand the various features users respond to and make design recommendations for alcohol cessation apps. This paper reports on three sources of feedback (user ratings, user reviews, MARS App Quality score) provided on 20 alcohol cessation apps in the Google Play Store. Our findings suggest that self-control type apps received much greater positive user reviews than motivational apps. In addition, this trend was not observed through numeric user ratings. We also speculate on design recommendations for apps that are meant to inhibit alcohol intake.

Reducing Internet Gambling Harms Using Behavioral Science: A Stakeholder Framework.

Internet gambling provides a unique environment with design mechanics and data-driven opportunities that can impact gambling-related harms. Some elements of Internet gambling including isolation, lack of interruption, and constant, easy access have been argued to pose specific risks. However, identifiable player accounts enable identification of behavioral risk markers and personalized private interfaces to push customized messages and interventions. The structural design of the Internet gambling environment (website or app) can have a strong influence on individual behavior. However, unlike land-based venues, Internet gambling has few specific policies outlining acceptable and unacceptable design practices. Harm minimization including responsible gambling frameworks typically include roles and responsibilities for multiple stakeholders including individual users, industry operators, government regulators, and community organizations. This paper presents a framework for how behavioral science principles can inform appropriate stakeholder actions to minimize Internet gambling-related harms. A customer journey through internet gambling demonstrates how a multidisciplinary nexus of collaborative effort may facilitate a reduction in harms associated with Internet gambling for consumers at all stages of risk. Collaborative efforts between stakeholders could result in the implementation of appropriate design strategies to assist individuals to make decisions and engage in healthy, sustainable behaviors.

Self-Quantification Systems to Support Physical Activity: From Theory to Implementation Principles.

Since the emergence of the quantified self movement, users aim at health behavior change, but only those who are sufficiently motivated and competent with the tools will succeed. Our literature review shows that theoretical models for quantified self exist but they are too abstract to guide the design of effective user support systems. Here, we propose principles linking theory and implementation to arrive at a hierarchical model for an adaptable and personalized self-quantification system for physical activity support. We show that such a modeling approach should include a multi-factors user model (activity, context, personality, motivation), a hierarchy of multiple time scales (week, day, hour), and a multi-criteria decision analysis (user activity preference, user measured activity, external parameters). This theoretical groundwork, which should facilitate the design of more effective solutions, has now to be validated by further empirical research.

Influencing beach littering behaviors through infrastructure design: An in situ experimentation case study.

Marine litter is one of the most pressing problems of our time and a major threat to ocean health; much of it comes from land-based sources, including from beachgoer activities. This study investigates how product design could influence littering behaviors of beachgoers when applied to beach trash cans (TCs). Over the course of six weeks three differently designed TCs were placed on a Mediterranean Sea tourist beach in Israel while observers tracked the behavior of 536 nearby groups ("entities") of beachgoers. Researchers analyzed: a) entities' locational choices; b) materials discarded in the TCs; and c) littering behaviors around the TCs. Based on the data collected, a "motivating" TC design performed best, encouraging the highest level of beachgoer interaction. Further research is needed in more and varied beach contexts, but this type of initial interdisciplinary research suggests how the design discipline could contribute to preventing marine litter from land-based sources.

The Internet as Cognitive Enhancement.

The Internet has been identified in human enhancement scholarship as a powerful cognitive enhancement technology. It offers instant access to almost any type of information, along with the ability to share that information with others. The aim of this paper is to critically assess the enhancement potential of the Internet. We argue that unconditional access to information does not lead to cognitive enhancement. The Internet is not a simple, uniform technology, either in its composition, or in its use. We will look into why the Internet as an informational resource currently fails to enhance cognition. We analyze some of the phenomena that emerge from vast, continual fluxes of information-information overload, misinformation and persuasive design-and show how they could negatively impact users' cognition. Methods for mitigating these negative impacts are then advanced: individual empowerment, better collaborative systems for sorting and categorizing information, and the use of artificial intelligence assistants that could guide users through the informational space of today's Internet.

A Weekly, Evidence-Based Health Letter for Caregivers (90Second Caregiver): Usability Study.

BACKGROUND: Informal caregivers are family members or close friends who provide unpaid help to individuals with acute or chronic health conditions so that they can manage daily life tasks. The greatest source of health information is the internet for meeting the needs of caregivers. However, information on the internet may not be scientifically valid, it may be written in language that is difficult to read, and is often in very large doses. 90Second Caregiver is a health letter whose aim is to disseminate knowledge to caregivers in a user-friendly, weekly format, in order to improve their wellbeing. OBJECTIVE: The main objective was to test a sample of 90Second Caregiver health letters in order to assess their usability and to optimize the design and content of the health letters. METHODS: Usability research themes were assessed using semi-structured phone interviews, incorporating the Think Aloud method with retrospective questioning. RESULTS: Usability was assessed in the context of five main themes: understandability and learnability, completeness, relevance, and quality and credibility of the health letter content, as well as design and format. Caregivers generally provided positive feedback regarding the usability of the letters. The usability feedback was used to refine 90Second Caregiver in order to improve the design and content of the series. Based on the results of this study, it may be of maximum benefit to target the series towards individuals who are new to caregiving or part-time caregivers, given that these caregivers of the sample found the letters more useful and relevant and had the most positive usability experiences. CONCLUSIONS: The findings assisted in the improvement of the 90Second Caregiver template, which will be used to create future health letters and refine the letters that have already been created. The findings have implications for who the 90Second Caregiver series should be targeting (ie, newer or part-time caregivers) in order to be maximally impactful in improving mental health and wellbeing-related outcomes for caregivers, such as self-efficacy and caregiving knowledge. The results of this study may be generalizable to the examination of other electronic health information formats, making them valuable to future researchers testing the usability of health information products. In addition, the methods used in this study are useful for usability hypothesis generation. Lastly, our 90Second delivery approach can generate information useful for a set of similar products (eg, weekly health letters targeted towards other conditions/populations).

Interactional theory of childhood problematic media use.

The growth of mobile device access and ownership has yielded many opportunities and challenges for raising healthy digital media consumers. As adoption of mobile and internet-connected devices has increased among children, concerns for healthy child development have been expressed regarding excessive or problematic use. Although much theoretical and empirical work has been conducted evaluating adolescents' and adults' risks for dependence on various screen media (e.g., Gaming Disorder, Internet Addiction), little theoretical consideration has been expounded regarding the etiology and maintenance of problematic media use earlier in childhood (i.e., under age 12 years). The purpose of this paper is to propose a theoretical framework through which to investigate problematic media use in early childhood. Our theory, the Interactional Theory of Childhood Problematic Media Use (IT-CPU) merges developmental and clinical psychology theories, with communication and human-computer interaction perspectives. We outline distal and proximal factors that we hypothesize contribute to the development of problematic media use in childhood, and emphasize maintaining factors that could be targets for intervention. Finally, we provide recommendations for an interdisciplinary research agenda to test our proposed theory and inform experimental trials to prevent and treat childhood problematic media use.

Embedding persuasive design for self-health management systems in Dutch healthcare informatics education: Application of a theory-based method.

The development of eHealth is dramatically changing the way healthcare is provided and organized. eHealth applications are used not only by healthcare professionals but also by patients specifically to self-manage their health condition. The development of eHealth applications requires a new methodological approach, departing from the more conventional methods dedicated to designing health information systems. There is a gap between theories to design persuasive eHealth applications and practices. In the Netherlands, eHealth innovation emerges from three areas. In research, the development of eHealth application often remains in a pilot phase. Healthcare organizations are also keen to innovate but do not always have the know-how. We further witness technology push from business and industry, undermining the co-creation process of the innovation. We consequently advocate an integrated, systematic and practical but scientifically based methodology to design effective persuasive eHealth applications. This approach is being successfully embedded in our educational health informatics program.

Examining Predictors of Real-World User Engagement with Self-Guided eHealth Interventions: Analysis of Mobile Apps and Websites Using a Novel Dataset.

BACKGROUND: The literature suggests that the product design of self-guided electronic health (eHealth) interventions impacts user engagement. Traditional trial settings, however, do not enable the examination of these relationships in real-world use. OBJECTIVE: This study aimed to examine whether the qualities of product design, research evidence, and publicly available data predict real-world user engagement with mobile and Web-based self-guided eHealth interventions. METHODS: This analysis included self-guided mobile and Web-based eHealth interventions available to the public-with their qualities assessed using the Enlight suite of scales. Scales included Usability, Visual Design, User Engagement, Content, Therapeutic Persuasiveness, Therapeutic Alliance, Credibility, and Research Evidence. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with websites and mobile apps, based on a time window of 18 months that was set between November 1, 2016 and April 30, 2018. Real-world user engagement variables included average usage time (for both mobile apps and websites) and mobile app user retention 30 days after download. RESULTS: The analysis included 52 mobile apps (downloads median 38,600; interquartile range [IQR] 116,000) and 32 websites (monthly unique visitors median 5689; IQR 30,038). Results point to moderate correlations between Therapeutic Persuasiveness, Therapeutic Alliance, and the 3 user engagement variables (.31≤rs≤.51; Ps≤.03). Visual Design, User Engagement, and Content demonstrated similar degrees of correlation with mobile app engagement variables (.25≤rs≤.49; Ps≤.04) but not with average usage time of Web-based interventions. Positive correlations were also found between the number of reviews on Google Play and average app usage time (r=.58; P<.001) and user retention after 30 days (r=.23; P=.049). Although several product quality ratings were positively correlated with research evidence, the latter was not significantly correlated with real-world user engagement. Hierarchical stepwise regression analysis revealed that either Therapeutic Persuasiveness or Therapeutic Alliance explained 15% to 26% of user engagement variance. Data on Google Play (number of reviews) explained 15% of the variance of mobile app usage time above Enlight ratings; however, publicly available data did not significantly contribute to explaining the variance of the other 2 user-engagement variables. CONCLUSIONS: Results indicate that the qualities of product design predict real-world user engagement with eHealth interventions. The use of real-world behavioral datasets is a novel way to learn about user behaviors, creating new avenues for eHealth intervention research.