Design and evaluation of online and mobile applications - VTT (PDF)

• V I S I O N S • S C I E N C E • T E C H N O L O G Y • R E S E A R C H H I G H L I G H T S Dissertation 55 Design and evaluation of online and mobile applications for stress management and healthy eating Kirsikka Kaipainen   VTT SCIENCE 55 Design and evaluation of online and mobile applications for stress management and healthy eating Kirsikka Kaipainen Thesis for the degree of Doctor of Philosophy to be presented with due permission for public examination and criticism in Tietotalo building, room TB219 at Tampere University of Technology, on the 16th of May 2014 at 12 noon.  ISBN 978-951-38-8123-8 (Soft back ed.) ISBN 978-951-38-8124-5 (URL: http://www.vtt.fi/publications/index.jsp) VTT Science 55 ISSN-L 2242-119X ISSN 2242-119X (Print) ISSN 2242-1203 (Online) Copyright © VTT 2014 JULKAISIJA – UTGIVARE – PUBLISHER VTT PL 1000 (Tekniikantie 4 A, Espoo) 02044 VTT Puh. 020 722 111, faksi 020 722 7001 VTT PB 1000 (Teknikvägen 4 A, Esbo) FI-02044 VTT Tfn. +358 20 722 111, telefax +358 20 722 7001 VTT Technical Research Centre of Finland P.O. Box 1000 (Tekniikantie 4 A, Espoo) FI-02044 VTT, Finland Tel. +358 20 722 111, fax +358 20 722 7001 Kopijyvä Oy, Kuopio 2014  “There must be balance in all things, or else the self will not hold.” - The Nameless One, Planescape: Torment “But I have no leisure for them at all; and the reason, my friend, is this: I am not yet able, as the Delphic inscription has it, to know myself; so it seems to me ridiculous, when I do not yet know that, to investigate irrelevant things.” - Socrates   5 Design and evaluation of online and mobile applications for stress management and healthy eating Stressinhallintaan ja terveelliseen syömiseen tarkoitettujen verkko- ja mobiilisovellusten suunnittelu ja arviointi. Kirsikka Kaipainen. Espoo 2014. VTT Publications 55. 95 p. + app. 98 p. Abstract Stress management and healthy eating are ongoing struggles for many people in the developed world. The consequences of chronic stress and unhealthy diets are borne at both individual and societal level. Currently, ischemic heart disease is the leading cause of death in the world, and depression is the leading cause of disabil- ity. Their early prevention calls for scalable and affordable means to provide sup- port for healthy dietary choices and daily recovery from stress. Modern technology offers potential solutions for daily self-management but few health-promoting ap- plications have reached widespread use despite promising research findings. The aims of this thesis were to assess the real-world use of health-promoting online and mobile applications, to evaluate their objective and subjective benefits, and to draw design guidelines for preventive applications. Six studies on online and mobile applications for stress management and healthy eating were conduct- ed with diverse settings and target groups. Two of the studies assessed the use of an online and a mobile application for healthy eating and found that less than 10% of the almost 200,000 users they attracted remained active. Two studies evaluated the benefits of technology tools combined with group intervention for stress man- agement and found improved well-being and active use of tools, although human contact was appreciated most. The last two studies analysed stress management applications and suggested new design principles for them. Based on the findings, freely available applications can reach a large number of users, but the attrition is likely to be very high and it is unclear whether the intend- ed audience is reached. Applications can contribute to improved well-being and provide support for behavioural changes and skills learning as long as they are simple, attractive and easy to integrate into everyday life. The design of applica- tions should support small daily actions that result in immediate benefits, empha- size self-improvement and reflection, and offer guidance while maintaining free- dom of choice. The results support the feasibility and applicability of online and mobile applications for health promotion at individual level and highlight the im- portance of a systematic theory-driven, user-centric and business-oriented ap- proach to intervention development. The societal impact of the applications may remain small unless real-world implementation, maintenance and dissemination are planned from the very beginning of the development process. Keywords health promotion, stress management, healthy eating, design, evaluation, adherence, behaviour change, online, mobile  6 Stressinhallintaan ja terveelliseen syömiseen tarkoitettujen verkko- ja mobiilisovellusten suunnittelu ja arviointi Design and evaluation of online and mobile applications for stress management and healthy eating. Kirsikka Kaipainen. Espoo 2014. VTT Science 55. 95 s. + liitt. 98 s. Tiivistelmä Stressinhallinta ja terveellinen syöminen ovat alituisen kamppailun aihe monille länsimaisille ihmisille. Niin yksilöt kuin yhteiskuntakin joutuvat vastaamaan pitkä- kestoisen stressin ja epäterveellisen ruokavalion seurauksista. Sepelvaltimotauti on tällä hetkellä maailman yleisin kuolinsyy, ja masennus on yleisin työkyvyttö- myyden syy. Varhainen puuttuminen ongelmiin edellyttää skaalautuvia ja edullisia keinoja, jotka tukevat terveellisiä syömisvalintoja ja päivittäistä stressistä palautu- mista. Nykyteknologia tarjoaa monia mahdollisuuksia päivittäiseen hyvinvoinnin hallintaan, mutta lupaavista tutkimustuloksista huolimatta vain harva terveyttä edistävä sovellus on päätynyt laajamittaiseen käyttöön. Tämän väitöskirjan tavoitteena oli selvittää terveyttä edistävien verkko- ja mo- biilisovellusten käyttöä oikeassa maailmassa, arvioida niiden objektiivisia ja sub- jektiivisia hyötyjä sekä kehittää suunnitteluperiaatteita ennalta ehkäiseville sovel- luksille. Stressinhallintaan ja terveelliseen syömiseen tarkoitettuja verkko- ja mobii- lisovelluksia tutkittiin kuudessa tutkimuksessa eri asetelmissa ja eri kohderyhmillä. Kahdessa tutkimuksista selvitettiin terveelliseen syömiseen tarkoitettujen verkko- ja mobiilisovellusten käyttöä ja havaittiin, että sovellusten tavoittamista lähes 200 000 käyttäjästä alle 10 % pysyi aktiivikäyttäjinä. Kaksi tutkimuksista arvioi teknologiavälineiden hyötyjä yhdistettynä ryhmämuotoiseen stressinhallintainter- ventioon ja havaitsi parannuksia hyvinvoinnissa sekä aktiivista välineiden käyttöä, joskin ihmiskontaktia arvostettiin eniten. Kaksi tutkimuksista analysoi stressinhal- lintasovelluksia ja esitti niille uusia suunnitteluperiaatteita. Löydösten perusteella vapaasti saatavilla olevat sovellukset voivat tavoittaa suuren joukon käyttäjiä, mutta käyttö on todennäköisesti hyvin lyhytaikaista, ja on epävarmaa, saavutetaanko oikea kohdeyleisö. Sovellukset voivat edistää hyvin- vointia ja tukea käyttäytymismuutoksia, jos ne ovat yksinkertaisia, kiinnostavia ja sopivia jokapäiväiseen elämään. Sovellussuunnittelun tulisi tukea pieniä päivittäisiä välitöntä hyötyä aikaansaavia tekoja, painottaa itsensä kehittämistä ja pohdintaa sekä opastaa säilyttäen kuitenkin valinnanvapauden. Tulokset puoltavat verkko- ja mobiilisovellusten hyödynnettävyyttä ja soveltuvuutta yksilötason terveyden edistä- miseen, mutta niissä korostuu myös suunnitelmallisen teorioihin perustuvan, käyt- täjäkeskeisen ja liiketoimintaa painottavan lähestymistavan tärkeys interventioiden kehittämisessä. Sovellusten yhteiskunnalliset vaikutukset voivat jäädä vähäisiksi, mikäli niiden käyttöönottoa, ylläpitoa ja levittämistä oikeassa maailmassa ei oteta heti alusta asti huomioon intervention kehitysprosessissa. Avainsanat health promotion, stress management, healthy eating, design, evaluation, adherence, behaviour change, online, mobile  7 Preface I have always loved a good story. As with any purposeful endeavour undertaken by a human being, there is a story behind this book. It is said that a researcher always influences the research setting by her mere presence. I feel that this works both ways – the researcher is heavily influenced by her research topics and espe- cially by the people she encounters and works with. These interactions form the basis for growth and learning which continue throughout life. The research presented in this thesis was carried out at VTT Technical Re- search Centre of Finland during 2009–2013. The original aim stated in my doctoral research plan was to increase knowledge about factors that influence a person’s health choices and to develop new preventive online and mobile applications. Looking back, this still sort of describes what I have done. However, the story had several unexpected turns and sub-plots, and the scope has broadened quite a bit. I have many remarkable people to thank for expanding my horizons. First and foremost, none of this would have happened without my advisor and supervisor, Professor Ilkka Korhonen. He first welcomed me to VTT as my team leader, then supervised my Master’s thesis, and subsequently helped me navigate through the murky waters of the PhD work. Ilkka, I am deeply grateful for all the support and advice you have given me and for the friendship I feel we have devel- oped over the years. You have inspired me to challenge myself in more ways than I could ever have imagined. The friends and co-workers at VTT and in the research projects deserve noth- ing but praise for their talent, insight and warmth. Special thanks go to Dr. Elina Mattila who has been a wonderful mentor and friend all the way from supporting my first wavering steps into health technology research. Thank you for your intelli- gence and humour and for sharing so much more than just the office with me. Furthermore, I deeply appreciate the support and leeway my team leaders Dr. Miikka Ermes and Dr. Toni Vanhala have given for pursuing meaningful research directions. Toni, thanks also for sharing the vision in how to change the world. Warm thanks for making the everyday work interesting and enjoyable to Anita Honka, Dr. Juha Pärkkä, Juho Merilahti, Kari Antila, Dr. Pasi Välkkynen, Marja Harjumaa, Docent Mark van Gils, and the rest of the folks in our merry teams. Your social support has been extremely valuable in the process.  8 I wish to express my appreciation to Research professor Niilo Saranummi for giving me the opportunity to delve into behavioural sciences in the PREVE project and beyond. You saw the big picture and reminded me many times that it really exists. Many thanks also to Anita Honka and Henri Hietala for the serious and not- so-serious reflections about human behaviour and business ecosystems. Even though the PREVE publications did not end up as a part of this thesis, the work carried out in the project set a solid theoretical basis for it. This research is a result of various collaborative efforts with creative and talent- ed people. I want to thank all of my fabulous co-authors including Dr. Elina Helander, Päivi Lappalainen, Aino Ahtinen, Tero Myllymäki, Dr. Antti Happonen, Dr. Marja-Liisa Kinnunen, Essi Sairanen, Henna Hoffrén, Antti Väätänen, Dr. Heikki Rusko and Dr. Collin R. Payne. Special thanks to Professor Raimo Lap- palainen whose experience, expertise and enthusiasm in combining psychology and technology have moved the field considerably forward and shaped my think- ing. I also thank the colleagues at TUT including Outi Kenttä, Janne Vainio, Dr. Hannu Nieminen and Harri Honko for fruitful discussions. I was incredibly fortunate to have the privilege to spend a year at Cornell Uni- versity in Ithaca, NY, during 2012. I am especially grateful to the two amazing people who spent huge amounts of their time on advising and entertaining me: Dr. Brian Wansink and Adam Brumberg. Brian and Adam, you both helped me strengthen my belief in my capabilities and encouraged me to challenge myself and push forward. I think you are shining examples of leadership and support. I also wish to thank Drew, Sandra, Julia, Margaret and Will for making my cultural adjustment easier and the office life entertaining, and Aner for arranging creative activities during free time as well. Moreover, the friendships I developed in Ithaca with fellow researchers from Europe will hopefully remain life-long. Kris and Simo- ne, you taught me a lot about the fundamentals of experimental research and the reunions like the one we had in Ghent need to continue. Alice and Daniela, I hope to meet you soon again. The other wise people I met in Ithaca, especially Charlie and Marjaneh, spurred my values clarification process by asking profound ques- tions. Ithaca is a special place and I left a piece of my heart there. Quite a few fellow researchers over the years have helped me structure my thinking and given a lot of food for thought. I mention only a few of you: Dr. Dan Lockton, Valentina Rao, Dr. Janet Davis, Dr. Tuomas Lehto, Dr. Niels Boye, Dr. Eija Kaasinen, Ting-Ray Chang, Dr. Misha Pavel and Dr. Holly Jimison. I also wish to thank Professor Pirkko Nykänen at University of Tampere for her encourage- ment and advice in the beginning of my PhD work. Furthermore, none of these studies would have been possible without the participants of the trials. I am grate- ful for the participants of all six studies for providing the data that is the source of all resulting insights, and Massive Health and Jawbone for granting access to the data analysed in Study II. Regarding the funding of the research, the P4Well project (Tekes – the Finnish Funding Agency for Technology and Innovation Grant 40011/08) and the Salwe Research Program for Mind and Body (Tekes – the Finnish Funding Agency for Technology and Innovation Grant 1104/10) have made the studies in this thesis  9 possible. I am extremely grateful for VTT Technology Manager Eero Punkka and my current team leader Johan Plomp for supporting the final steps of the thesis process. Financial support from Finnish Cultural Foundation is gratefully acknowl- edged. I sincerely thank the pre-examiners of this thesis, Professor Harri Oinas- Kukkonen and Docent Nelli Hankonen, for their thorough and valuable comments and suggestions that helped to reflect upon the work and improve the thesis a great deal. I am also deeply honoured to have Dr. Ionela Petrea and Professor Harri Oinas-Kukkonen as my opponents. Finally, I am fortunate to have such wonderful family and friends. I inherited my love of books and learning from my parents, who also helped me believe that people can do anything they put their minds to. Hilla, my sister in so many ways, you are a shining light of empathy and goodwill. You have given me more strength and hope than you can imagine (and you have a very creative imagination). Ville, I tried to follow your footsteps before realizing I need to find my own path. Still, it was not a bad way to start. Thank you both for the inspiring growth environment and for the opportunity to get to know your adorable significant others Sampo and Thao. I give a grand salute to all my friends and especially Milla, Heikki, Terjo, Laura, Ari and Mikko for helping me regain my sanity through relaxing activities. Last but certainly not the least, I express my deepest and warmest gratitude to my beloved Aki. You are the kindred spirit I always hoped to encounter, and you never fail to lift my spirits and fill my heart with joy. Thank you for your patience and support for stress management and healthy eating especially during my mad writing stints. Let’s see what wonders the next chapter of our story together will reveal. Tampere, April 2014 Kirsikka Kaipainen  10 Academic dissertation Supervisor Professor Ilkka Korhonen Department of Signal Processing Tampere University of Technology Finland Reviewers Professor Harri Oinas-Kukkonen Department of Information Processing Science University of Oulu Finland Docent Nelli Hankonen Faculty of Social Sciences, Social Psychology University of Helsinki Finland Opponents Dr. Ionela Petrea Department of International Mental Health Policy Trimbos Institute The Netherlands Professor Harri Oinas-Kukkonen Department of Information Processing Science University of Oulu Finland  11 List of original publications This thesis is based on the following original publications, which are referred to in the text as Studies I–VI. The publications are reproduced with kind permission from the publishers. I Kaipainen, K., Payne, C.R. & Wansink, B. (2012). Mindless Eating Chal- lenge: Retention, weight outcomes, and barriers for changes in a public web-based healthy eating and weight loss program. Journal of Medical In- ternet Research, 14(6), e168. II Helander, E., Kaipainen, K., Korhonen, I. & Wansink, B. (2014). Factors re- lated to sustained use of a free mobile app for dietary self-monitoring with photography and peer feedback: Retrospective cohort study. Journal of Medical Internet Research, 16(4), e109. III Lappalainen, P., Kaipainen, K., Lappalainen, R., Hoffrén, H., Myllymäki, T., Kinnunen, M.-L., Mattila, E., Happonen, A.P., Rusko, H. & Korhonen, I. (2013). Feasibility of a personal health technology-based psychological in- tervention for men with stress and mood problems: Randomized controlled pilot trial. JMIR Research Protocols, 2(1), e1. IV Kaipainen, K., Mattila, E., Väätänen, A., Happonen, A.P., Korhonen, I., Kin- nunen, M.-L., Myllymäki, T., Lappalainen, P., Hoffrén, H., Rusko, H. & Lap- palainen, R. (2010). Web, mobile and monitoring technologies in self- management of psychophysiological wellbeing: Usage and user experiences. Proceedings of the IADIS International Conference e-Health 2010, Freiburg, Germany, 29–31 July, 2010, pp. 167–177. V Kaipainen, K., Mattila, E., Kinnunen, M.-L. & Korhonen, I. (2010). Facilita- tion of goal-setting and follow-up in an Internet intervention for health and wellness. Proceedings of the 5th International Conference on Persuasive Technology (PERSUASIVE 2010), Copenhagen, Denmark, 7–10 June, 2010, pp. 238–249. VI Ahtinen, A., Mattila, E., Välkkynen, P., Kaipainen, K., Vanhala, T., Ermes, M., Sairanen, E., Myllymäki, T. & Lappalainen, R. (2013). Mobile mental well- ness training for stress management: Feasibility and design implications based on a one-month field study. JMIR mHealth & uHealth, 1(2), e11.  12 Author’s contributions The author’s contributions to the individual publications of the thesis were as follows: I The author had the main responsibility for designing and performing the da- ta analysis and was the primary author of the publication. II The author obtained the data for the study from the developers of the appli- cation, performed the initial exploratory data analysis, provided several of the main study questions and participated in data analysis and interpretation. The author wrote half of the publication. III The author participated in the planning and execution of the randomized controlled trial and had the main responsibility for analysing the impact of technology. The author wrote the technology-related sections of the publi- cation. IV The author had the main responsibility for the study of user experiences and she was the primary author of the publication. The author participated in the study design and execution and implemented the portal evaluated in the study. V The author had the main responsibility for the analysis of lessons learnt and for the new design. The author also implemented the improved version of the portal. She was the primary author of the publication. VI The author played a key role in designing the concept and structure of the application, and she participated in the planning of the study and interpreta- tion of the results. The author wrote most of the related work section of the publication, contributed substantially to writing the discussion and was re- sponsible for half of the revisions.  13 Contents Abstract ........................................................................................................... 5 Tiivistelmä ....................................................................................................... 6 Preface ............................................................................................................. 7 Academic dissertation ................................................................................... 10 List of original publications........................................................................... 11 Author’s contributions .................................................................................. 12 Abbreviations ................................................................................................ 15 1. Introduction ............................................................................................. 16 2. Health promotion .................................................................................... 19 2.1 Health promotion at individual level ................................................... 19 2.2 Stress management.......................................................................... 23 2.2.1 Stress and coping .................................................................. 23 2.2.2 Stress management interventions .......................................... 24 2.2.3 Acceptance and commitment therapy ..................................... 24 2.3 Healthy eating .................................................................................. 26 2.3.1 Healthy diet and nutrition........................................................ 26 2.3.2 Healthy eating interventions ................................................... 26 2.3.3 Small-changes approach to changing eating habits ................. 27 3. Health promotion with online and mobile applications .......................... 29 3.1 Design of health-promoting applications ............................................ 29 3.1.1 Design factors related to adherence and outcomes ................. 30 3.1.2 Evaluation approaches ........................................................... 32 3.2 Online and mobile applications for stress management and healthy eating ............................................................................................... 34 3.2.1 Stress management applications ............................................ 34 3.2.2 Healthy eating applications..................................................... 36