How to design a health app for users who are not motivated to change? Insights from the Precious app

The Precious app was designed to support healthy living: a physically active lifestyle, balanced nutrition and stress management. In a study published in JMIR mHealth and uHealth, we describe how we designed the Precious physical activity app features for users whose needs are not met by traditional activity tracker apps.

Most available physical activity apps provide factual information on performance with numbers and graphs, and they can be a great resource for those who are already active and who want to monitor their progress. Millions of users regularly log their running and cycling routes using smartphone sensors or wearables that connect with apps such as Strava. However, not everyone enjoys physical activity, and not everyone finds numerical data meaningful. For some, constantly failing to reach the goals set by exercise apps (such as 10,000 steps a day) can be a major stressor. Although good health is the goal for many, sometimes people only feel motivated to take care of themselves after facing a serious health concern.

Physical activity is good for our physical and mental wellbeing and those with the lowest levels of activity would benefit most from adopting some exercise in their life. Building on psychological research on motivation and self-regulation, we came up with two ways of catering to users with low motivation for activity in the Precious app: reflective and spontaneous support.

Reflective support through Motivational Interviewing

Most of us know about the health benefits of a physically active lifestyle. Thus, there is little need to remind people what they should do. Somewhat surprisingly, psychological research shows that a much more effective strategy is to help people think what they want to do [1].

In the Precious app, we used Motivational Interviewing techniques [1] to support people who struggle to fit physical activity into their daily lives. One of the key techniques is to ask questions that help the users reflect on how healthy behaviours could help them reach goals that are meaningful for them. When users start to express their desire to change or the reasons to become active, they are eliciting change talk. This is a central concept in Motivational Interviewing: helping people to put into words how behavioural changes can help them live a life that corresponds to their values.

In the Precious app, users are first guided to think about what really matters to them. This does not need to be health related: the basic psychological needs for human motivation are connectedness to others, experiencing competence in their actions, and having the freedom to pursue personally meaningful goals. [2] This thinking is based on Self-Determination Theory which has repeatedly shown that individuals engage in behaviours when these are in line with their values and identity [3].

Once the users have reflected on their life values, they are encouraged to think about if physical activity could help them achieve those things. Among the test users of the Precious app, physical activity was typically perceived as helpful, as physical exercise can, for instance, increase energy levels and help to manage stress. Whether people prioritise their family, their health or their career, improved physical and mental well-being is an asset.

The next step is to help users think about practical ways in which physical activity can take them closer to their life goals. For instance, if a user has indicated that feeling connected to others is most important to them, they can choose activities that can be done together with family or friends. The aim of the Motivational Interviewing tools is not simply to engage users with the app, but to engage them in the behaviour change process: to actively consider reasons for change and to take practical steps toward change (see Figure 1).

Figure 1. Screenshots from the Precious app.

Spontaneous support through gamification

Behaviour change does not necessarily require active reflection but can tap into the motivational effect of intrinsic pleasure. Gamification is the use of game elements for making a task more engaging and entertaining. For instance, the Conquer the city feature in the Precious app was designed to increase walking by making users conquer and defend areas in the area they live in by walking around buildings or blocks. Game elements can change users’ focus from feeling like they are ‘just walking’ to the task at hand and make people spontaneously active without even realising. Similar ideas have gained success in games like Ingress, Pokemon Go or Zombies, run!, where augmented reality elements lure players to walk further or run faster. An activity that is not necessarily fascinating in itself can become more enjoyable with augmented reality elements. People who do not find physical activity pleasurable may enjoy gamified visualisations, goals and challenges that they only achieve while being active.

The ‘Mountain climber’ tool provides a visual interpretation of activity and goal achievement

Following these principles, the evidence-based self-regulatory behaviour change techniques [4] in the Precious app were built into a Mountain climber tool (see Figure 2). It depicts daily activity as a mountain and shows a little flag on top of the mountain on days when users achieved their personal step goal. This self-regulation tool was designed so that people could monitor their daily steps even without looking at numbers. They can see if their mountain panorama is growing over time and learn what type of activities lead to the highest mountains.

Figure 2. The ‘Mountain climber’ tool.

To help users estimate more accurately how much activity they have done every day, the planning tool in the Precious app indicates how many steps each activity corresponds to. Users can fill in the minutes they spent swimming, lifting weights, etc., and the app will display how many steps these activities correspond to using MET values. All activities contribute to the daily step count and are visualised as one mountain, providing an easy day-to-day comparison.

The Precious app tries to convey that people do not need to become athletes in order to be physically active. Vacuuming the house or helping a friend to move can be the dose of daily physical activity – a realisation that can be a relief for someone with a busy schedule! The main thing is to make physical activity more enjoyable, or to at least see how it can help achieve things that matter most.

Questions

• The Precious app helped users elicit change talk in the interview situation. Will the effect carry on in a natural environment, over time?
• Health apps can be tailored to meet the needs of people with low technology literacy and little motivation for behaviour change, but how do we reach these potential users?

Read more:

Nurmi J, Knittle K, Ginchev T, Khattak F, Helf C, Zwickl P, Castellano-Tejedor C, Lusilla-Palacios P, Costa-Requena J, Ravaja N, Haukkala A. (2020). Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and Feasibility Testing of the Precious App. JMIR mHealth and uHealth. DOI: 10.2196/12884 URL: https://mhealth.jmir.org/2020/1/e12884/

Johanna Nurmi is finalising her PhD in Social Psychology at the University of Helsinki and working as a visiting researcher at the Behavioural Science Group, University of Cambridge. She studies how motivational techniques and related cognitions affect individuals’ daily physical activity. Johanna’s research has been supported by the University of Helsinki; the Yrjö Jahnsson foundation; and the KAUTE foundation.

The Precious project was funded by the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement number 611366, and built in multidisciplinary collaborations with partners across Europe.

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