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Course overview and structure

Dates: May 23-June 20, no class May 28Times: 5:30-8:30pm ET + team meetingsWhat to do if missing all or part of class?

Meet in person: for class session, separately, or not at all?Twitter and other social media

Social media surveyOnline course feedback: you are not guinea pigs!

Questions: l.gualtieri@tufts.edu, cell: 781-330-9456

dickie.wallace@tufts.edu, cell 413-335-3803

Mobile Health

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Healthy People 2020

• Health Communication and Health Information Technology • …many ways health communication and health IT can have

a positive impact on health, health care, and health equity. They include…– Providing personalized self-management tools and resources– Building social support networks– Delivering accurate, accessible, and actionable health information

that is targeted or tailored– Increasing health literacy skills– Providing sound principles in the design of programs and

interventions that result in healthier behaviors– Increasing Internet and mobile access

• http://healthypeople.gov

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Mobile is only part of digital landscape

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Cell phone use in US

• 82% of adults in the US own a cell phone• Unlike the internet, which has been associated

with a large digital divide, mobile phones are being used by people in – All geographic settings– Across all age and racial/ethnic groups– Pew Research Center 2011

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Smartphone owners by age

• Smartphone adoption has grown more than 54% in the past year to 82.2 subscribers (9/11/11)

• 36.1% of Americans 13+ use smartphone

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Smartphone growth is across all ages

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What exactly is an app – and what isn’t?

• Mobile development – Mobile websites are similar to regular websites, typically

with browser pages built in HTML5, but are tailored for the smaller display and touch-screen interface

– Native apps are downloadable programs on a smartphone and dependent upon phone’s operating system

– Hybrid apps are mobile sites wrapped in HTML5 and presented as a native app

• Many issues with multi-platform development• Many websites don’t accommodate mobile use well

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Android Phones and iPhones Dominating App Downloads in US

• 83% of app downloaders (in past 30 days) use iPhone or Android smartphones

• Which is best choice?

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Popularapp

examples

Lifestyle/Health

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Unintended consequences: Words with Friends

Source: Words With Friends Apple iPhone app screen shots

Insurance: low frequency but mutually advantageous

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Having apps and using themare not synonymous

• 26% who download health apps use them only once– Pamela Culver, Yahoo! News, 3/21/11

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Mobile user experience

• What got me thinking about the entire experience of learning about, downloading, and using apps

• Dimensions of mobile design

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Saugus, MA

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Kowloon app

Everyone wants to have or think they need an app – like web

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Mobile design is the entire experience

• Having a need and/or learning about an app• Deciding to download• Deciding to try - initial use• Sustained or ongoing use • Participatory or shared use• Not a continuum• May be dips• Can an app be successful with only initial or sporadic use?• Are incentives necessary and which work?• Is trust necessary and at which point(s)?• How is health different from commerce or entertainment?

How do people learn about apps?

• Pre-downloaded• Signs on doors• App stores

– Search based on categories, cost, featured, etc.– Easier for iPhone because similar to iPod music?– Android Market to Google Play– Many of these provide ratings and reviews

• Participation is spotty

• Review sites• Recommendations and word-of-mouth• Ads, pop-ups, product packaging, TV, etc.

Why do people decide to try an app?

• Low barriers• Hope to improve or simplify one’s life

– Entertainment– Satisfy unmet need– Satisfy unidentified need

• Commerce?

– Accomplish something otherwise not possible– Accomplish something more easily than before

• Convenience

– Integrate disparate aspects of life– Smart and/or innovative

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Designing mobile user experience

• Smartphone capabilities– Also limitations relative to desktop/laptop

• Smartphone layout and patterns– De facto standards are emerging

• Apps are changing what people do

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Smartphone in contrast to desktop/laptop• Screen size and proportions

– Less screen real estate and more variety in screen proportions• Direct interaction with screen

– No mouse so no roll-overs or tool-tips– Only some have keyboard so users interact directly with the screen

• Variable orientation– Quick orientation switching

• Single-screen environment– Hard to use multiple apps simultaneously even when possible

• Established device standards– As market matures, consistent UI patterns are forming

• Limited resources– Smartphones are limited by connection quality, battery life,

processing power, and onboard memory

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Touchscreen inputs

• Touchscreen inputs include:– Single tap: used in place of a standard mouse click– Drag: scrolling or panning– Flick: scroll of pan quickly – Swipe: make selection, evoke a contextual menu, or

as part of a two step process like delete– Pinch (open & close): zooming in/out– Press and hold: make a selection or evoke a

contextual menu

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Smartphone controls and capabilities• Smartphone controls and capabilities for input/output

– Visual: high resolution screen– Audible: speaker, headphone jack– Physical: vibration for alerts, haptic feedback – Dedicated keys: Volume control, Back, Search, Menu,

Power/Lock, Home– Physical keyboards: shortcuts, text input– Accelerometers: track motion and orientation – GPS– Backlight– Microphone: voice commands, ambient audio, music – Camera: photos and visual codes

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Mobile design patterns: de facto standards have emerged

• Activity Feeds• Check-in Screens• Comment Detail• Custom Tab Navigation• Dashboard Navigation• Edu Walk-Throughs • Empty Data Sets• Find Friends• Grouped Table Views• Lists• Maps• Notifications• Search• Settings• Sign Up Flows• Splash Screens• UI that I Heart• User Profiles• Venue Detail

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Mobile design patterns for navigation• Important because it is the most visible screen and therefore needs to

be appealing and usable– Springboard (Facebook)– Simple or expanding list menu (Blackboard)– Tab menu (Foursquare)– Gallery (Android gallery)– Dashboard– Metaphor

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Design rules apply – even more so

• Make first experience positive• Make subsequent experiences helpful and

compelling• Consistency between screens• Similar metaphors to other apps, as appropriate• Well-written text• Judicious use of imagery• Name and branding• Creative use of mobile capabilities!

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Applying user experience design to apps – and the app store!

• Appeal– Immediate reaction– Recommend to friend– Rate or review

• Usability– Easy to accomplish tasks

and know capabilities• Effectiveness

– Accomplish goals– Sustain use

4 dimensions of mobile design

• Mobile users use their mobile device in any location no matter what else they are doingContext

• Mobile users use their mobile device at a moment’s notice including for urgent needsImmediacy

• Mobile users have an ongoing intimate and personalized relationship with their digital appendage and, through it, with others

Affinity

• “Big data” and predictive analytics offers extensive personalization and tailoring (but too invasive?)

Personaliza-tion

Smartphone use for health

• Opportunities through social networking• SMS/texting• Mobile browser• Apps

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Social mobile health

• Managing health habits involves managing social relationships, not just targeting a specific health behavior for change - Bandura

• Mobile devices have increased the ways in which individuals can access, receive, and provide social support

• Is facilitation of social support through mobile devices enough?

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Mobile health interventions

• Mobile browser use• Voice and text messaging interventions have been shown

to – Increase quit rates among smokers– Motivate healthy eating and physical fitness– Facilitate self-management of asthma and diabetes

• Interventions to record/send personal health data to a provider using mobile phone improved treatment adherence for diabetes, asthma, and cancer patients– Issue with where responsibility lies

• Research suggests that patient attitudes regarding this type of intervention are relatively positive

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Mobile access to health information• 2/3 of mobile users used browsers instead of apps

to find health information

Who uses health apps?

• Individuals with varying– Demographics– Health literacy skills– Health needs– Medical knowledge and

experience– Skills– Disabilities– Cultural and language

differences– Economic situations

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Future growth• More than 44 million mobile health apps will be

downloaded in 2012; more than 142 million by 2016 (Juniper Research)

• Market for mobile health technology, valued at $120 million in 2010, is expected to exceed $400 million by 2016 (ABI Research reported in eWeek 11/23/11)

• Growth triggers– Health-related apps may offer proven techniques in the future;

FDA said it will begin requiring regulatory review and software validation (Yahoo! News, 3/21/11)

– Development of more consumer-focused apps, with fitness-related apps dominating followed by home monitoring for seniors

– Potential cost savings through remote patient monitoring– More peripheral devices (weight scales, blood pressure monitors,

and glucose meters) that attach to mobile phones

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Consumer Health Apps

Types of health apps

• 4+ categories– Educate– Connect– Track– Remind– “Detect”

• Some apps do many of these• Gamification can encompass track and connect• Some apps learn from history and patterns of use• But how many incorporate context, immediacy, affinity, and

personalization?– Location-based donut example– Restaurant example

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Research

• “No studies have assessed how well health-related apps change behaviors primarily because academic research tends to lag behind innovation in technology” – LiveScience/Fox News, 3/21/11

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Limited research to date

• Evaluation of iPhone apps for smoking cessation– App’s approach to cessation, its adherence to clinical

practice guidelines, and its frequency of downloads– 11.3% of apps strongly followed a given guideline– 4.3% of apps strongly followed the guideline to connect

a user with a Quitline– 8.5% of apps made use of intra-treatment social support

• Apps that had the lowest adherence scores were also the most downloaded– Measuring downloads only measures downloads!– Abroms

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Analysis of diabetes apps compared to evidence-based guidelines

• Research on both the design and the use of diabetes mHealth applications is scarce

• 60 diabetes apps on iTunes for iPhone in July 2009; 260 in February 2011

• Contrasted the prevalence of self-monitoring, education, alerts and reminders, etc. with clinical guideline recommendations for diabetes self-management

• “…obvious gaps between the evidence-based recommendations and the functionality used in study interventions or found in online markets. Current results confirm personalized education as an underrepresented feature in diabetes mobile applications”– Taridzo Chomutare et al., Norwegian Centre for Integrated Care and

Telemedicine, University Hospital of North Norway, Tromsø, Norway

Definitions of Obesity Body Mass Index (BMI) of 30 or higher

BMI A measure of an adult’s weight in relation to his or

her height Specifically the adult’s weight in kilograms divided by

the square of his or her height in meters

Weight Loss Apps:Obesity Trends Among US Adults 1985 and

2010

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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Obesity and demographics

• Obesity affects some groups more than others– Non-Hispanic blacks have the highest rates of obesity (44.1%) compared

with Mexican Americans (39.3%), all Hispanics (37.9%) and non-Hispanic whites (32.6%).

• Obesity and socioeconomic status– Among non-Hispanic black and Mexican-American men, those with

higher incomes are more likely to be obese than those with low income.– Higher income women are less likely to be obese than low-income

women.– There is no significant relationship between obesity and education among

men. Among women, however, there is a trend—those with college degrees are less likely to be obese compared with less educated women.

– Between 1988–1994 and 2007–2008 the prevalence of obesity increased in adults at all income and education levels

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Healthy Weight Initiative (CDC)

• Recommendations designed for patients to promote healthy weight management strategies

• Available at: http://www.cdc.gov/healthyweight/index.html

• Guidelines that may inform mobile app development– 5 steps to weight loss or preventing weight gain:

http://www.cdc.gov/healthyweight/losing_weight/getting_started.html

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5 Steps from Healthy Weight Initiative 1. Make commitment

– Write contract that includes goals for accountability – Record important motivators

2. Define current health status and lifestyle – Assess current weight– Identify current eating and exercise habits – Identify factors that help and hinder a healthy lifestyle

3. Set goals– Set very specific short and long-term goals related to diet and exercise – Establish rewards to work toward

4. Access resources for education and support – Identify resources to enable weight loss/healthy diet

5. Monitor progress – Continuously monitor diet and weight & progress with respect to

established goals – Record barriers/obstacles and rewrite goals to address these issues

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Weight Management App Reviews and Descriptions

• Were best-practices guidelines used?– Not clear from app reviews or the descriptions of these apps in app

stores that the apps’ developers consulted best-practices guidelines for weight management prior to app design

– Few reviews of weight management apps (and other health apps) and few app store descriptions mention evidence-base at all; focus is on features

• How customizable?– Some apps allow patients to create a customizable weight

management plan but mostly based on age, gender and weight loss goals

– Few apps accommodate weight management needs of special populations, such as dietary restrictions (vegan, gluten-free) or health conditions that might influence how a weight management program is planned and implemented

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Research questions• How do you define app success and learn from experiences?• Is facilitation of social support through mobile devices

enough in of itself?• Do existing evidence-based guidelines apply to mobile

devices as is?– If not, how can they be “adjusted” or reframed?

• Are new techniques needed to evaluate apps?– Not successful for web yet – HONcode, URAC

• Are mobile literacy skills needed?– Are mobile health literacy skills needed too?

• How can health and public health organizations get a foothold with increasingly commercially-driven approaches?

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Mobile First

• Designing for mobile first instead of retrofitting existing practices into mobile format

• Is what is best for people what is most successful in the marketplace?– Evaluation and market research only go so far– My apps were mobile first

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App challenges

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My app design• Business travelers

have increased rates of poor health and health risk factors, including obesity and high blood pressure

• Many apps help locate restaurants based on cost, location, and ethnicity

Mobile Design Challenge

• Design app for Parents are the Key– Mobile first– Focus on scenario: inputs and outputs– Incorporate mobile design principles of context,

immediacy, affinity, and personalization