Development of “LvL UP 1.0”: a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

BackgroundNon-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, “LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.Materials and MethodsA multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.ResultsPreliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily “Life Hacks” (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.ConclusionsThe development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers

Revolutionizing Nutrition Education: Trends, Innovations, and Prospects in Learning Media

This comprehensive study conducts an in-depth analysis to explore the dynamic landscape of nutrition learning media research, aiming to delineate evolving trends, developmental trajectories, and their consequential implications. Employing bibliometric analysis and content analysis approaches, this research uncovers distinct publication patterns and citation behaviors, spotlighting pronounced trends catalyzed by the COVID-19 pandemic, a testament to the adaptability of educational systems. The study identifies a spectrum of learning media formats, encompassing applications, websites, and game-based platforms, while emphasizing the prevalence of experimental and design methodologies within the research paradigm. Keyword clusters elucidate strategies integrating technology and catering to diverse target audiences. In conclusion, nutrition education media plays a pivotal role in addressing health and sustainability challenges. The study advocates for ensuring equitable access to digital resources and advocates for fostering interdisciplinary collaboration as pivotal facets for future research endeavors. Ultimately, this research significantly contributes to enhancing nutrition literacy and underscores the transformative potential of technology-driven education in empowering informed dietary decisions and augmenting overall health outcomes.

A framework to influence the behavioural intention of adults to monitor their health using gamification: a case of discovery vitality in East London, South Africa.

The epidemic of overweight or obesity conditions has become a public health concern in South Africa, and signifies major challenges of chronic diseases affecting the healthcare sector. Recent years have noted the increasing prevalence of gamification and development across all age groups. The rapid adoption and use of gamification as a tool to improve adult motivation and engagement when monitoring their health and wellness is an essential form of health intervention. Gamification allows its users to keep track of their health in real time and encourages an active healthy lifestyle behaviour. Research has found that there are factors that may inhibit the behavioural intention of adults to use gamification for health monitoring in the long term. These factors include cost or membership fees associated with gamification that uses Discovery Vitality and privacy concerns. The main aim of this research study was to develop a framework to influence the behavioural intention of adults to monitor their health through gamification making use of Discovery Vitality as the case study. The self-determination theory was used as the theoretical framework to ensure continuance usage of gamification for sustained health monitoring. A qualitative research approach was chosen for this study. The purposive sampling technique was selected to identify 20 adults between the ages of 18-59 years that are members of Discovery Vitality in East London, South Africa. Interviews were conducted with the 20 participants to identify the factors that will influence their behavioural intention to make use of gamification to monitor their health. After data collection, thematic analysis was used to analyse the data and the data provided by the participants was organised and summarised into relevant themes to answer the main research question. The study developed a framework which incorporated the four constructs of the self-determination theory, namely perceived autonomy, competence, relatedness and satisfaction of basic psychological needs for sustained health monitoring. The study also developed the five factors influencing the behavioural intention of adults to continue using gamification for sustained health monitoring. These factors are known as: broad appeal, applicability and accessibility through mobile technology and pervasive sensors, development and accomplishment, employment of creativity and feedback, and lastly social influence and relatedness. The recognition of weight loss, tracking and monitoring of physical activities and medication adherence was found to positively influence the behavioural intention of adults to continuosly use gamification to monitor their health.Thesis (MCom) (Information Systems) -- University of Fort Hare, 202

A framework to influence the behavioural intention of adults to monitor their health using gamification: a case of discovery vitality in East London, South Africa.

The epidemic of overweight or obesity conditions has become a public health concern in South Africa, and signifies major challenges of chronic diseases affecting the healthcare sector. Recent years have noted the increasing prevalence of gamification and development across all age groups. The rapid adoption and use of gamification as a tool to improve adult motivation and engagement when monitoring their health and wellness is an essential form of health intervention. Gamification allows its users to keep track of their health in real time and encourages an active healthy lifestyle behaviour. Research has found that there are factors that may inhibit the behavioural intention of adults to use gamification for health monitoring in the long term. These factors include cost or membership fees associated with gamification that uses Discovery Vitality and privacy concerns. The main aim of this research study was to develop a framework to influence the behavioural intention of adults to monitor their health through gamification making use of Discovery Vitality as the case study. The self-determination theory was used as the theoretical framework to ensure continuance usage of gamification for sustained health monitoring. A qualitative research approach was chosen for this study. The purposive sampling technique was selected to identify 20 adults between the ages of 18-59 years that are members of Discovery Vitality in East London, South Africa. Interviews were conducted with the 20 participants to identify the factors that will influence their behavioural intention to make use of gamification to monitor their health. After data collection, thematic analysis was used to analyse the data and the data provided by the participants was organised and summarised into relevant themes to answer the main research question. The study developed a framework which incorporated the four constructs of the self-determination theory, namely perceived autonomy, competence, relatedness and satisfaction of basic psychological needs for sustained health monitoring. The study also developed the five factors influencing the behavioural intention of adults to continue using gamification for sustained health monitoring. These factors are known as: broad appeal, applicability and accessibility through mobile technology and pervasive sensors, development and accomplishment, employment of creativity and feedback, and lastly social influence and relatedness. The recognition of weight loss, tracking and monitoring of physical activities and medication adherence was found to positively influence the behavioural intention of adults to continuosly use gamification to monitor their health.Thesis (MCom) (Information Systems) -- University of Fort Hare, 202

Development of “LvL UP”, a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background: Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, “LvL UP”, a digital lifestyle intervention aimed at preventing NCDs and CMDs.Materials and Methods: A multidisciplinary team led the intervention design process of LvL UP, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding (prototype development), and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.Results: The first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks” (healthy activity suggestions), breathing exercises, and journaling. Engagement components involve motivational interviewing and storytelling to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a digital device.Conclusions: The development process of LvL UP led to an evidence-based and user-informed digital health intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers

The evaluation of social media to increase engagement rate, reach and health education: the case for WoW!

Introduction: In 2021, South Africans had a 51.9 percent chance of dying from an NCD. The Western Cape on Wellness (WoW!) program advocates for wellness, through partnership, innovation and policy, including health in communities, worksites and schools. Increasing knowledge and awareness regarding health behaviors and NCD risk factors is an important pathway in preventing and mitigating the problem at hand through a combination of structural and social policy change. Social media provides an unprecedented opportunity and innovative way to provide a solution to the problem. The internet has increasingly become a popular source of health information by connecting individuals with health content, experts, and support. Aim & Objective: To use a social media campaign with expert knowledge to change healthy lifestyle actions and increase health knowledge and engagement in a para-social western cape on wellness social media group. Methods: A mixed methods quantitative and qualitative analysis was undertaken to assess key messages, which were publicly available on the WoW! Facebook group. 60 lifestyle messages were posted on the WoW! Facebook group 5 times a week from Monday through to Friday. Each message was disseminated by a moderator and followed a theme for the day. Three icons were used to measure levels of participant engagement likes, shares, comments. Associated comments were extracted and coded using a codebook based on items from the supportive accountability model and peer social support analysis. The identified search material was reviewed allowing removal of any personally identifying or geographical material in order that that the comments were rendered anonymous. One –way ANOVA was performed to determine whether level of likes, shares and comments differed between posts. One-way ANOVA was performed to determine whether level of engagement differed between post types, with Tukey–Kramer test used to determine post hoc differences. An independent samples t-test was conducted to determine whether total engagement differed between moderator initiated posts and Facebook user-initiated posts. Results: The most common form of engagement was "likes," and engagement was higher for moderator initiated rather than participant-initiated posts. Overall traffic to the page increased over the 3 month period from 1083 WoW! Facebook users to 1300. Likes were the most common and easiest form of engagement (M=7.6, SD 9.8) with comments being the lowest (m=0.81, SD 2.3). The most engaged with and resonative messages were the #transformationthursday posts. Empirically physical activity behaviour and change in eating patterns did increase over time. The 7 main themes that were identified constituted 53.3% (112/210) of all comments in the pre and during campaign analyses. The most prevalent theme was social cohesion and connectedness at 29% (33/112). The least common theme was developing professional communication and organisational support at 4.5% (5/112). Overall, there were more comments before the campaign (n=63), than during (n=49). In terms of Geographical proximity most of the comments and posts came from participants in the Metro (58.3%) and rural districts Paarl (48.3%) and George (40%). A proximal or virtual tie to a place adds connection and thus value to the information. Conclusion: The favourable results of the WoW! Facebook campaign shows promise for future social media-driven health campaigns to educate and prevent lifestyle related chronic conditions. Social media content for knowledge sharing should be created through a well-intentioned process with the support of moderators to facilitate the conversation and drive engagement

Mobile health data: investigating the data used by an mHealth app using different mobile app architectures

Mobile Health (mHealth) has come a long way in the last forty years and is still rapidly evolving and presenting many opportunities. The advancements in mobile technology and wireless mobile communication technology contributed to the rapid evolution and development of mHealth. Consequently, this evolution has led to mHealth solutions that are now capable of generating large amounts of data that is synchronised and stored on remote cloud and central servers, ensuring that the data is distributable to healthcare providers and available for analysis and decision making. However, the amount of data used by mHealth apps can contribute significantly to the overall cost of implementing a new or upscaling an existing mHealth solution. The purpose of this research was to determine if the amount of data used by mHealth apps would differ significantly if they were to be implemented using different mobile app architectures. Three mHealth apps using different mobile app architectures were developed and evaluated. The first app was a native app, the second was a standard mobile Web app and the third was a mobile Web app that used Asynchronous JavaScript and XML (AJAX). Experiments using the same data inputs were conducted on the three mHealth apps. The primary objective of the experiments was to determine if there was a significant difference in the amount of data used by different versions of an mHealth app when implemented using different mobile app architectures. The experiment results demonstrated that native apps that are installed and executed on local mobile devices used the least amount of data and were more data efficient than mobile Web apps that executed on mobile Web browsers. It also demonstrated that mobile apps implemented using different mobile app architectures will demonstrate a significant difference in the amount of data used during normal mobile app usage

Mobile exergaming in Type 2 Diabetes mellitus – innovative ways to overcome physical inactivity and increase exercise adherence

Background Type 2 diabetes has developed into a worldwide pandemic in recent years that is associated with vast comorbidity and mortality and has created an enormous financial strain on health care systems all around the globe. Physical inactivity is known to be one of the most important risk factors for the development of type 2 diabetes and responsible for much of the diabetes‐related comorbidity. An increase in regular physical activity is therefore an essential component of a successful type 2 diabetes treatment. However, despite the proven benefits of regular physical activity, the vast majority of patients with type 2 diabetes remain inactive – often due to low motivation and lack of physical activity enjoyment. A recent and promising approach to motivate sedentary individuals to be more physically active and sustainably adhere to regular physical activity is exergames. These games integrate physical activity and personal health information into a game or game‐like setting and thereby promote physical activity through playful and enjoyable challenges. Aims The aims of this Ph.D. project were: (1) to systematically review the current evidence for the effectiveness of exergaming in overweight and type 2 diabetes and (2) to evaluate the suitability of the Wii Fit Plus exergame to improve cardiorespiratory fitness in individuals with type 2 diabetes. The aim was further (3) to develop a behavior change technique‐based smartphone game that delivers individualized exercise and physical activity promotion with the intention to motivate inactive type 2 diabetes patients to become sustainably physically active and to plan a 24‐week randomized controlled trial evaluating the game’s effectiveness. In addition, it was aimed (4) to assess the accuracy of a commercial activity wristband and of iOS and Android smartphones to measure steps during various walking conditions as those devices were intended to be used to measure the primary outcome (steps per day) in the 24‐week randomized controlled trial. Finally, the aims were (5) to examine the effectiveness of the smartphone game to increase daily physical activity and improve glycemic control and aerobic capacity as well as (6) to evaluate the game’s suitability to increase the intrinsic physical activity motivation and elicit sustained improvements in physical activity adherence in inactive individuals with type 2 diabetes over a 24‐week period. Methods In this Ph.D. project, one systematic review and three studies were conducted. In the systematic review, electronic bibliographic databases (PubMed, Embase, Web of Science, OpenGrey, and the Cochrane Central Register of Controlled Trials) were searched up to March 2015. Randomized controlled trials and cross‐sectional studies published in English in peer‐reviewed journals were included. Included studies were required to have analyzed the effects of exergames on objectively measured intensity parameters of physical activity (oxygen uptake, energy expenditure, and heart rate) in overweight adults with and without type 2 diabetes. In study 1, data collected from a study conducted by Prof. Schmidt‐Trucksäss before the start of my Ph.D. was analyzed to evaluate the cardiorespiratory exertion (maximum and mean oxygen uptake) of 12 elderly individuals with type 2 diabetes during 10‐minute bouts of different Wii Fit Plus exercises. Oxygen uptake values were compared to the maximally reached values during a previously conducted cardiopulmonary exercise test on a treadmill. Correlations between oxygen uptake values reached during exergame activity and those reached during the all‐out exercise test were analyzed using Spearman’s rank correlation coefficient. Following this preparatory work and considering its results, I collaborated with an international team consisting of sports scientists, gamification researchers, professional game developers, and clinical professionals in developing an innovative smartphone game with the aim to encourage a healthier, more active lifestyle through gamified physical activity in inactive type 2 diabetes patients. To evaluate the effectiveness of the game to sustainably increase physical activity in the target group, I planned a 24‐week randomized controlled trial with daily physical activity (steps per day) as the primary outcome. To verify the validity of the devices used to measure the primary outcome (steps per day) in the 24‐week intervention study, I conducted a validation study in an additional investigation of this Ph.D. project. In the study, 20 participants were equipped with 3 iPhone SE smartphones (placed in pants pocket, shoulder bag, and backpack), 1 Samsung Galaxy S6 Edge (pants pocket), 1 Garmin Vivofit 2 wristband, and 2 ActiGraph wGTX+ devices (worn at wrist and hip) and instructed to walk for five minutes at four predefined walking speeds (1.6, 3.2, 4.8, and 6.0 km/h) and to complete an outdoor walking course. Video observation was used as gold standard. Validity was evaluated by comparing each device with the gold standard using mean absolute percentage errors. In the main study (ClinicalTrials.gov identifier NCT02657018) of this Ph.D. project, 36 inactive, overweight type 2 diabetes patients between 45 and 70 years of age were randomly assigned to either the intervention group or the control group. Participants in the intervention group received the self‐developed smartphone game, and participants in the control group were instructed to implement the recommendations from the baseline lifestyle counseling autonomously during the 24‐week intervention period. Before and after the intervention period, steps per day were objectively measured during six consecutive days. In addition, glycemic control (HbA1c) was measured by analysis of venous blood, and aerobic capacity (oxygen uptake at the first ventilatory threshold) was assessed during an all‐out exercise test on a bike ergometer. Intrinsic physical activity motivation was assessed with an abridged 12‐item version of the Intrinsic Motivation Inventory (IMI). In the intervention group, adherence to the game‐proposed physical activity recommendations during the intervention period was additionally assessed via the phonerecorded game usage data. Analyses of covariance with adjustment for the respective preintervention values were used to compare changes in outcome parameters (steps per day, HbA1c, oxygen uptake at the first ventilatory threshold, and IMI score) between the two groups. Correlations between game use (min) and change in steps per day as well as change in workload (W) at the first ventilatory threshold were analyzed using Spearman’s rank correlation coefficient, and a linear regression model was used to assess the relationship between total in‐game training (min) and change in IMI total score. Results Publication 1: Effects of Exergaming on Physical Activity in Overweight Individuals. [1] The systematic review showed that exergames are able to increase physical activity among overweight individuals. However, the magnitude of this increase as well as the intensity of the exergame‐related physical activity and consequently their suitability to offer a guidelineconcordant training is greatly dependent on the console and the game mode as well on the duration of play. The majority of the included studies were of poor or moderate methodological quality. No studies exist that objectively assess the effect of exergames on daily physical activity in type 2 diabetes, and the cross‐sectional nature of all included studies does not permit judgement on whether exergames are suitable to increase physical activity in the long term. A general lack of adequate individualization of the intensity and difficulty level was noted for all exergames, making most game modes unsuitable for an effective training and potentially unsafe for inactive individuals with chronic diseases and a likely reduced fitness level. Publication 2: Cardiorespiratory Exertion While Playing Video Game Exercises in Elderly Individuals With Type 2 Diabetes. [2] In elderly type 2 diabetes patients, carefully selected Wii Fit Plus exercises elicit peak values in oxygen uptake that correspond to 60% of the maximally reached values during an all‐out treadmill test. Mean values were just above 40% for all exercises and were thus in a range that corresponds to current exercise guidelines. A moderate‐to‐strong positive correlation between the peak oxygen uptake during exergame play and the maximal value reach during the exercise test was found, indicating that subjects with a higher fitness level were able to exercise at a higher intensity during exergame play than individuals with a lower fitness level. Publication 3: Mobile Exergaming for Health – Effects of a Serious Game Application for Smartphones on Physical Activity and Exercise Adherence in Type 2 Diabetes Mellitus – Study Protocol for a Randomized Controlled Trial. [3] The self‐developed and innovative game takes the proven motivational benefit of exergames into consideration and further extends them by integrating established behavior change techniques into an elaborate storyline. Shortcomings with regard to the suitability and effectiveness of the exercise regimen of current exergames are addressed by offering a fitness level‐adjusted training with an individualized rate of intensity progression that is based on the performance in established and in‐game‐conducted exercise tests. Publication 4: Validity of Activity Trackers, Smartphones, and Phone Applications to Measure Steps in Various Walking Conditions. [4] The Garmin Vivofit 2 and iPhone SE showed good accuracy for treadmill walking ≥3.2 km/h (<3% deviation from video recordings) and for free walking thus being suitable to measure steps at normal, fast, and even slow walking speeds. The Samsung Galaxy S6 Edge showed good accuracy (<3% deviation from video recordings) for treadmill walking ≥4.8 km/h and for free walking, demonstrating suitability to measure steps during normal and fast walking. The good validity of the iPhone SE was found independently of the phone’s position (pants pocket, backpack, shoulder bag), suggesting a broad versatility of the device for physical activity measurement in various settings. Publication 5: Publication 5 Behavior Change Technique‐based Smartphone Game Sustainably Increases Daily Physical Activity in Type 2 Diabetes Patients – A Randomized Controlled Trial. [5] In persistently inactive type 2 diabetes patients, a novel self‐developed smartphone game that follows a cognitive/behavioral approach and incorporates individualized exercise regimens and physical activity recommendations elicited significant and clinically meaningful increases in daily physical activity (+4,000 steps per day) over a 24‐week period, classifying the participants as sufficiently active post‐intervention (average of 9,782 steps per day). The increase in daily physical activity was accompanied by an increase in aerobic capacity with a significantly higher oxygen uptake and workload at the first ventilatory threshold. Total duration of in‐game training was positively correlated with the change in steps per day and the change in workload at the first ventilatory threshold. Glycemic control (HbA1c) did not change during the intervention period; however, as indicated by the significant adjusted difference in HbA1c of ‐0.9 percentage points in favor of the intervention group, there is reason to assume that regular use of the game supports the stabilization of glycemic control in medically well‐controlled patients. In the control group, none of the outcome parameters changed significantly during the intervention period. Publication 6: Effectiveness of a Behavior Change Technique‐based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Type 2 Diabetes Patients: A Randomized Controlled Trial. [6] The 24‐week randomized controlled trial further showed that participants in the intervention group significantly increased their IMI‐measured intrinsic physical activity motivation during the intervention period. Participants in the control group did not show any significant changes in their intrinsic physical activity motivation. The analysis of the usage data revealed that participants in the intervention group used the game for an average of 143.1 (SD 59.1) minutes of in‐game training per week, which underlines the game’s potential in motivating formerly inactive type 2 diabetes patients to meet and sustainably adhere to established physical activity recommendations. Conclusions A novel smartphone game that incorporates established motivational elements and personalized physical activity recommendations into an elaborate storyline elicits clinically relevant increases in daily physical activity and aerobic capacity and contributes to a medically well‐regulated glycemic control in persistently inactive type 2 diabetes patients. The game is therefore a suitable treatment option to motivate inactive individuals to increase daily physical activity that may be relevant for other inactive target groups with and without chronic diseases. Future research should further refine the game design as well as the motivational and physical activity‐related content to make it an even more comprehensive treatment tool for various target groups

:Gamification & Serious Game : Symposium 2016, July 4 & 5

Reinforcing the bridge between local academic and applied worlds in the domain of Serious Game & Gamification, e.g. applied universities and startups. Focusing on three application domain, Helath, Social, and Education, the figure next page illustrates the variety of short talks of the symposium. The three categories of talks (among 14 corresponding short papers): five concept-oriented in green, nine demo-oriented in black, and three roundtables