Changing Behaviour with Apps
While much of medical science focuses on the treatment of disease, there is growing recognition in health care around the importance of disease prevention through the promotion of healthy behaviours. An Ontario-based study suggests that 60 per cent of deaths are attributable to poor health behaviours. In fact, life spans would increase by seven years on average if five key unhealthy behaviours — excessive alcohol consumption, poor diet, physical inactivity, high stress and smoking — were eliminated . Unfortunately, we all know this is easier said than done.
Changing behaviour can be very challenging and requires ongoing resources to build knowledge, motivation and confidence among those ready to change. Primary care clinicians can be a key resource in this journey, but we often lack the resources and tools to do the job well . In fact, the recent Commonwealth Fund Survey states that in the last two years, only 41 per cent of Canadians have talked to a physician about healthy diet, and only 23 per cent have discussed alcohol use .
The growth of mobile health apps provides an exciting opportunity to support healthy behaviour changes using advances in digital technology. Digital apps can support behaviour change through a variety of features including education, tracking, reminders and social networking . The explosion of “wellness” apps and devices highlights the potential of digital technology in health promotion.
The vast majority of these apps, however, are made by large private companies, usually geared to the U.S. or international market. Although these may still provide benefit to Canadian, there are often factors that don’t quite fit a Canadian context. This review is the first of two that focus on apps designed in Canada for Canadians to promote healthy behaviours. While these apps may not have as many bells and whistles as some from larger private corporations, most are well made, have reputable partners and integrate into the clinical guidelines we already use. Among those reviewed here, Carrot Rewards is especially promising as it integrates with popular fitness trackers to offer Canadians tangible rewards for improving their health.
EaTracker was created by the Dieticians of Canada with support from the B.C. Ministry of Health. The app’s main feature is its ability to track detailed nutritional intake based on meals entered by the user. This requires users to find meals from a long – but culturally limited – list or manually enter each ingredient into a meal. Activity can be tracked, but must be entered manually with no integration into popular fitness trackers. The app is actively support by the dieticians at EatRight Ontario who can provide some guidance for Ontario-based users. The app was generally reliable with a clear privacy statement. Unfortunately, clumsy manual entry of diet and fitness information and a lack of culturally diverse meals means the usefulness of the app is limited for some patients. Motivated patients who desire a detailed understanding of nutrition might find this app helpful in their quest for a healthier lifestyle.
The app is a bit of a catch-all of exercise and fitness related features, but its core functionality is the ability to track dietary intake with a detailed nutritional breakdown. Users can add common foods, get a detailed nutritional analysis based on the Canadian Nutrient File and compare their intake to daily recommended nutrient guidelines. The app’s biggest drawback is that it does not include many popular meals, especially dishes originating outside North America. While the website enables users to add individual ingredients to create a meal, this is time consuming and requires a patient and motivated user. Users can also specify healthy lifestyle goals and track activity levels through manual entry. There was no obvious way to export the data or integrate details into other clinical systems.
Partnerships with reputable health agencies including the B.C. Ministry of Health and Dieticians of Canada is a key strength of eaTracker. The app alone has a minimal feature set and is unlikely to lead to significant behaviour change in users. However, the app is supported by the dieticians at EatRight Ontario and may provide a useful tool for motivated individuals as part of a large suite of resources.
The app only allows users to enter meals and fitness activity, with the more complicated features reserved for the website. Adding an item is difficult as the user must search through long detailed lists to find the desired entry. The lack of activity integration with common fitness trackers is a significant usability limitation. The app provides a dashboard of daily food and activity but it is not visually appealing or easy to interpret.
Privacy & Security+-
Although the app crashed once during use, it was generally responsive and quick. It was last updated in March 2017 and continues to have strong support from its partners. There is no error checking, meaning the user can enter extreme, unrealistic values.
The app is available free on both Android and iOS platforms. However, it requires access to a computer to set up most features. The lack of pre-specified meals from multiple cultures means many patients will not find it relevant or useful.
My Food Guide
This simple app created by Health Canada enables users to review Canada’s Food Guide and explore food options in each category. While it has a relatively limited feature set, its bright visuals and easy navigation make it enjoyable to use. The app focuses on understanding nutrition using food groups and not calories, as most apps do. This is likely better for some patients. Users can add foods they enjoy to each food group. There is no way to track daily intake. The app collects minimal health information and is being actively updated. Overall, this app is likely too basic for many patients motivated to improve their health but would be helpful for those who need to learn the basics of nutrition and require a simple, easy-to-use app to get them started.
This is a relatively simple app that allows users to explore their nutrition needs based on Canada’s Food Guide. After entering their age and sex, users can see how many servings of each food group they should be eating daily. Users can then enter examples of common foods in each category. The lists are not exhaustive, but do reflect some cultural diversity. The app would benefit from also allowing users to explore the Eat Well Plate that is often used in nutritional counselling .
The app’s use of Canada’s Food Guide means it will be familiar to first-time users looking to understand nutrition basics. However, it is likely too basic for more motivated patients who want to track daily intake or refine their diet based on more detailed nutritional measures. The app is lacking behaviour-change features such as reminders, tracking or social media integration.
The app has appealing, colourful visuals that help emphasize the different food groups. The navigation buttons are clear and intuitive. Overall, using the app is a simple and enjoyable experience.
Privacy & Security+-
The app is actively supported, with the last update to the Android app in May 2017. It was quick and responsive with no crashes during testing.
The app is available for free on Android and iOS. Its use of colour and visuals means the app may still be useful to those with low-level English. This app would benefit from additional languages and increased culturally diversity in listed foods.
Carrot Rewards provides Canadians in B.C., Ontario and Newfoundland with rewards points for completing educational quizzes and improving their activity levels. Created with a unique public-private partnership, Carrot Rewards works with health agencies, including the Public Health Agency of Canada, to encourage priority health behaviours among the population. Users earn real points on one of several popular reward programs for common items like gas, movies and flights by tracking activity levels and completing educational quizzes.
The app syncs with common fitness trackers and rewards users for meeting challenges to increase their step count. While there are no studies showing positive impact on activity levels, it is evident that the company uses known behaviour change concepts to drive healthy behaviours. The app is well designed, with a pleasant and intuitive interface. It has broad appeal and will be relevant to all but the most motivated and knowledgeable patients. Overall, despite the lack of clear evidence of effectiveness, this app has few drawbacks and can be a tool regularly recommended by primary care providers as part of an ongoing partnership to promote healthy behaviours in their patients.
Carrot Rewards provides Canadians in B.C., Ontario and Newfoundland with rewards points for completing educational quizzes and improving their activity levels. The app syncs with Apple Health Kit, Fitbit and Google Fit to automatically monitor activity levels. After establishing a baseline, the app challenges users to an increased level of activity and provides points when the target is met. Further, once or twice a week, the app prompts users to complete educational quizzes on topics such as salt intake or mental health, promoting ongoing engagement. Users can easily review daily activity levels and progress towards meeting the set challenges. There was no clear method to export data or share it with the user’s health care team.
Carrot Rewards’ strong partnerships with public health agencies means its content aligns with strategic health goals in the province: healthy eating, physical activity and smoking cessation in Ontario. A study of initial use in B.C. showed strong engagement in quizzes over three months, especially among urban females. Long-term engagement or impact on activity change was not studied . The app clearly uses known behaviour change principles in its language and features to increase engagement and motivation among users. The education quizzes are easy to understand and provide accurate information, but may be too basic for users with high levels of health knowledge.
The app was easy to set up and sync with Google Fit. Users can easily connect to existing rewards accounts by entering their account number. Overall the app is well designed with an appealing interface that is intuitive to use. The controls and text are large, making navigation easy for all users. The language is concise and easy to understand, with a helpful FAQ.
Privacy & Security+-
The app is actively updated with ongoing support from many public health agencies. It was quick and responsive with no crashes during testing. Tech support responded within 24 hours with helpful advice. Automated tracking significantly decreases the risk of erroneous data.
The app Is available for free on both Android and iOS platforms. It can only be accessed by users in three provinces: Ontario, B.C. and Newfoundland. The language is accessible and clear, and is available in English and French.
Whether or not patients take your advice and use mobile apps to help them change behaviour and improve their health may rely on four little words.
In 2000, Nicolas Gueguen, Université de Bretagne-Sud – Vannes and Alexandre Pascual, Université de Bordeaux 2 – Bordeaux, sent PhD students into the street to beg for bus fare. When subjects were asked to give money, only 10 per cent of the sample acceded. However, 47.5 per cent gave money when the students finished their request with these words, “but you are free to accept or to refuse.” This technique, called the “but you are free” technique, tends to increase compliance with a request but also increases the subject’s involvement. That’s because it takes into account “reactance” – our knee-jerk response to the sense our autonomy is threatened.
The “but you are free” phrase was shown to not only increase how much bus fare people gave, but, as reported by Nir Eyal, was also effective in boosting charitable donations and participation in voluntary surveys. In fact, a recent meta-analysis of 42 studies involving more than 22,000 participants concluded that a few words, placed at the end of a request, are a highly effective way to gain compliance, doubling the likelihood of people saying “yes.” (Eyal, a Stanford graduate, writes about the intersection of psychology, technology, and business and how technology shapes user behaviour by creating new habits.)
With this in mind, you should likely take reactance into account when recommending behaviour change apps to your patient – but, of course, you are free to accept or refuse our advice.
- Douglas G. Manuel, R.P., Carol Bennett, Seven More Years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. 2012, Institute of Clinical Evaluative Sciences, Public Health Ontario.
- Cohen, D.J., et al., Implementing Health Behavior Change in Primary Care: Lessons From Prescription for Health. Annals of Family Medicine, 2005. 3(Suppl 2): p. s12-s19.
- Eric C. Schneider, D.O.S., David Squires, Arnav Shah, Michelle M. Doty, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. 2017, The Commonwealth Fund.
- K. Singh, K.D., L. P. Newmark et al., Developing a Framework for Evaluating the Patient Engagement, Quality, and Safety of Mobile Health Applications. 2016, The Commonwealth Fund.
- Mitchell, M., et al., Uptake of an Incentive-Based mHealth App: Process Evaluation of the Carrot Rewards App. JMIR Mhealth Uhealth, 2017. 5(5): p. e70.
- Build a healthy meal: use the Eat Well Plate. 2016 Sept 1, 2016 [cited 2017 Aug 8, 2017]; Available from: http://www.healthycanadians.gc.ca/eating-nutrition/healthy-eating-saine-alimentation/tips-conseils/interactive-tools-outils-interactifs/eat-well-bien-manger-eng.php.