JMIR MHEALTH AND UHEALTH Nurmi et al
Original Paper
Engaging Users in the Behavior Change Process With Digitalized
Motivational Interviewing and Gamification: Development and
Feasibility Testing of the Precious App
Johanna Nurmi1,2, MSocSc‡; Keegan Knittle1, PhD; Todor Ginchev3, MS; Fida Khattak3, MS; Christopher Helf4, MSc;
Patrick Zwickl5, PhD; Carmina Castellano-Tejedor6,7, PhD; Pilar Lusilla-Palacios8,9, PhD; Jose Costa-Requena3, PhD;
Niklas Ravaja10, PhD; Ari Haukkala1,11, PhD
1Discipline of Social Psychology, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
2Behavioural Science Group, Primary Care Unit, University of Cambridge, Cambridge, United Kingdom
3Communications and Networking Department, School of Electrical Engineering, Aalto University, Espoo, Finland
4Department of Entertainment Computing, University of Vienna, Vienna, Austria
5Center For Digital Safety And Security, Austrian Institute of Technology, Vienna, Austria
6Department of Psychiatry, University Hospital Vall d’Hebron, Vall d’Hebron Institute of Research, Barcelona, Spain
7Department of Basic Psychology, Grup de Recerca en Estrès i Salut, Autonomous University of Barcelona, Bellaterra, Spain
8Servicio de Psiquiatría, Hospital Universitari Vall d’Hebron, Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona,
Barcelona, Spain
9Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Vall d’Hebron Institut de Recerca, Barcelona, Spain
10Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
11Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
‡Written on behalf of the Precious Project Consortium
Corresponding Author:
Johanna Nurmi, MSocSc
Discipline of Social Psychology
Faculty of Social Sciences
University of Helsinki
Unioninkatu 37
PO Box 54
Helsinki, 00014
Finland
Phone: 358 44 504484297
Email: johanna.nurmi@helsinki.fi
Abstract
Background: Most adults do not engage in sufficient physical activity to maintain good health. Smartphone apps are increasingly
used to support physical activity but typically focus on tracking behaviors with no support for the complex process of behavior
change. Tracking features do not engage all users, and apps could better reach their targets by engaging users in reflecting their
reasons, capabilities, and opportunities to change. Motivational interviewing supports this active engagement in self-reflection
and self-regulation by fostering psychological needs proposed by the self-determination theory (ie, autonomy, competence, and
relatedness). However, it is unknown whether digitalized motivational interviewing in a smartphone app engages users in this
process.
Objective: This study aimed to describe the theory- and evidence-based development of the Precious app and to examine how
digitalized motivational interviewing using a smartphone app engages users in the behavior change process. Specifically, we
aimed to determine if use of the Precious app elicits change talk in participants and how they perceive autonomy support in the
app.
Methods: A multidisciplinary team built the Precious app to support engagement in the behavior change process. The Precious
app targets reflective processes with motivational interviewing and spontaneous processes with gamified tools, and builds on the
principles of self-determination theory and control theory by using 7 relational techniques and 12 behavior change techniques.
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The feasibility of the app was tested among 12 adults, who were asked to interact with the prototype and think aloud. Semistructured
interviews allowed participants to extend their statements. Participants’ interactions with the app were video recorded, transcribed,
and analyzed with deductive thematic analysis to identify the theoretical themes related to autonomy support and change talk.
Results: Participants valued the autonomy supportive features in the Precious app (eg, freedom to pursue personally relevant
goals and receive tailored feedback). We identified the following five themes based on the theory-based theme autonomy support:
valuing the chance to choose, concern about lack of autonomy, expecting controlling features, autonomous goals, and autonomy
supportive feedback. The motivational interviewing features actively engaged participants in reflecting their outcome goals and
reasons for activity, producing several types of change talk and very little sustain talk. The types of change talk identified were
desire, need, reasons, ability, commitment, and taking steps toward change.
Conclusions: The Precious app takes a unique approach to engage users in the behavior change process by targeting both
reflective and spontaneous processes. It allows motivational interviewing in a mobile form, supports psychological needs with
relational techniques, and targets intrinsic motivation with gamified elements. The motivational interviewing approach shows
promise, but the impact of its interactive features and tailored feedback needs to be studied over time. The Precious app is
undergoing testing in a series of n-of-1 randomized controlled trials.
(JMIR Mhealth Uhealth 2020;8(1):e12884)  doi: 10.2196/12884
KEYWORDS
health app; mHealth; human-computer interaction; prevention; service design; usability design; intrinsic motivation; reflective
processes; spontaneous processes; engagement; self-determination theory; autonomous motivation; gamification; physical activity
Introduction [22], and users may spend less time with smartphone apps thancomputer-delivered interventions [6,23]. To engage users and
Background build sustained motivation and commitment in the process of
behavior change, apps need to offer more support than just
Lifestyle-related diseases, such as cardiovascular diseases, type tracking behaviors.
2 diabetes, and cancers, lead to a decrease in quality of life and
are the leading causes for years of life lost worldwide [1]. Engaging Users in the Behavior Change Process With
Stretched health care resources struggle with the complications an App
that could, in many cases, be avoided with a physically active Engagement in digital interventions is conceptualized in
lifestyle [2,3]. There is a need for interventions that can different ways in different research traditions. Within behavioral
effectively support people to achieve the amount of physical literature, engagement often refers to the frequency or duration
activity that is necessary for their health and well-being. of time spent using a digital service [24-26]. This summative
As a consequence, hundreds of thousands of smartphone health engagement, the quantitative metrics of usage time and
apps have emerged for tracking physical activity. With their frequency, is not enough for understanding neither the user
interactive features, onboard sensors, and associated wearables, experience in the moment-to-moment interaction with the app
smartphones are a natural tool for tracking and self-monitoring nor how apps support active involvement in the behavior change
activity [4,5]. Individuals tend to carry phones with them and process and the intervention goals [27-29]. Some studies have
keep them switched on continuously [6], use apps repeatedly found low frequency of usage being as effective as higher
for brief moments between other activities [6], and value this frequency [30], and increased usage time can even be a symptom
possibility for ubiquitous support [7]. of low usability instead of engaging content [30].
Tracking physical activity is indeed a key element of many Within the usability and gaming literature, engagement is
successful physical activity interventions. Self-regulatory typically conceptualized as the subjective user experience with
behavior change techniques (BCTs) [8] related to control theory the service, including affect, interest, attention, and flow [26].
[9], such as self-monitoring, goal setting, action planning, Studying user experience can provide information on how
feedback on behavior, and problem solving, have been immersive an app is but does not typically explain cognitive
consistently linked with positive changes in physical activity engagement in the process of behavior change—a health app
[10]. The more actively individuals enact these techniques, the may be entertaining and have good usability but does not
more effective interventions are [11-14]. necessarily engage the user to reflect their behavior or make
them take steps to approach their goals.
Smartphone apps have shown promise in reducing sedentary
behaviors [15,16], but the evidence for increasing physical In this study, we have defined engagement as active involvement
activity is modest [16-20]. One factor that explains this may be with the behavior change process that the app is aiming for.
the importance of face-to-face contact for physical activity This includes all the steps the user takes toward behavior change,
motivation [21]. For smartphone apps to achieve the same for instance, by reflecting reasons for change or engaging in
effectiveness as interventions delivered in person, apps should planning and monitoring of the behavior in question. This
be engaging enough for users to keep returning to receive the concept of engagement with the behavior change process is
necessary support. However, user commitment to smartphone close to effective engagement, which refers to the level of active
apps is low: 22% of downloaded apps are opened only once
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involvement that is necessary for the intervention to achieve One reason for the limited use of motivational interviewing may
intended outcomes [27,31]. be its lack of having a coherent theoretical framework, which
creates challenges for testing the specific mechanisms of action
It is recognized that the effectiveness of a digital service depends
and linking studies to theoretical discussions in the field [41].
on the target behaviors (one-time action or lifestyle change),
Thus, the self-determination theory has been suggested as the
the BCTs used, and individuals using the service and their
theoretical basis for the method, as it shares core principles with
subjective user experience [26,31]. We have proposed that the
motivational interviewing [41].
effectiveness of a digital service also depends on the extent to
which the individuals get cognitively involved in the process Self-Determination Theory
of behavior change: whether interaction with an app encourages Motivation research leaning on the self-determination theory
users to think about their reasons, capabilities, and opportunities [42] has established that the quality of motivation predicts
to change and whether the interaction increases their motivation individuals’ physical activity levels [43,44]. Individuals with
and self-efficacy to change. To examine this concept of active high autonomous motivation are more likely to engage in regular
cognitive engagement in the behavior change process, we used physical activity than those with externally controlled
the approach widely used in face-to-face behavior change motivations, such as guilt and shame for not being active or
counseling (ie, motivational interviewing). pressure from others. Autonomous motivation consists of the
Motivational Interviewing following two elements: (1) motivational regulation that is based
on the pleasure of the activity itself (ie, intrinsic motivation)
Motivational interviewing is a person-centered counseling
and (2) motivational regulation that is guided by goals that are
method that provides practical techniques for improving
separate from the behavior but in line with the person’s values
intervention engagement and commitment to the behavior
and identity (ie, identified or integrated regulation). Promoting
change process [32]. In addition to content-focused BCTs,
these different forms of autonomous motivation may require
practical tools for self-regulation, motivational interviewing
different intervention strategies. Individuals are also more likely
offers tools for the interaction quality between the counselor
to engage in active self-regulation when their motivation for
and the client, suggesting several relational techniques and
physical activity is autonomous [45-47]. Self-determination
methods for fostering the alliance and engaging the client in the
theory–based interventions address autonomous motivation by
process [33,34]. Core elements of motivational interviewing
aiming to satisfy the psychological needs of autonomy,
include resolving ambivalence toward behavior change, eliciting
competence, and relatedness [48].
reflection and change talk, individuals’ self-expressed language
in favor of change, and supporting client autonomy [32]. Autonomy refers to the freedom to organize one’s own
Motivational interviewing uses collaborative and experiences and behavior in accordance with one’s integrated
nonauthoritarian interaction to work toward clients’ goals [32]. sense of self [42]. It can be supported by, for instance, offering
choice and a meaningful rationale of the relevance of the
Face-to-face motivational interviewing and telephone-delivered
behavior, by respecting and acknowledging individuals’
motivational interviewing have increased exercising and strength
viewpoints, and by avoiding controlling or guilt-inducing acts
training and reduced sedentary time [35,36]. A systematic
and language.
review of technology-delivered adaptations of motivational
interviewing showed promise for a variety of health-related Experiences of competence can be offered through clear
behaviors [37]. However, only two of the computer-based instructions and expectations, collaborative goal setting, and
interventions targeted physical activity, and none of the optimally challenging tasks, providing tailored strategies and
interventions tested smartphone delivery [37]. feedback as well as guidance and skills training. Competence
is closely related to Bandura’s concept of self-efficacy [49],
Motivational Interviewing Increases Intervention which describes an individual’s perceptions of their own
Engagement capabilities to perform a behavior.
Motivational interviewing can lead to improved health outcomes
through enhancing participant adherence and intervention Relatedness includes processes that create a meaningful
engagement. It has improved engagement with various behavior connection, convey understanding, and engage participants with
change intervention components, including attendance to the process [48]. In addition to actual persons participating or
behavioral weight loss programs [38], and self-monitoring of supporting the behavior change, the connection can be
food intake and blood glucose [35]. For instance, improved experienced with individuals who would benefit from the change
program attendance has led to more comprehensive (eg, getting fitter to be a better team member or focusing on
self-monitoring diaries, which again have enhanced weight loss one’s health to have more energy to spend with family). A
outcomes [39]. digital intervention may also provide a sense of relatedness with
the service, for instance, through experiencing the good
Despite the evidence for improving intervention engagement intentions of the people providing the service. Relatedness to
in face-to-face interventions, motivational interviewing–type the intervention provider may be supported by taking the user’s
motivational support is rarely present in health apps for perspective with empathy, displaying appreciation or concern,
smartphones. For instance, Pagoto et al [40] screened the involving the person, gathering knowledge about the person
hundred most popular apps for weight loss and found that none and paying careful attention to them, dedicating time and energy,
of them provided BCTs for low adherence and motivation. and being available when needed [50].
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Smartphones provide many opportunities for supporting these psychological needs and support autonomous motivation. This
needs, for instance, by offering accurate and usage-based or increased awareness of the pleasure and benefits of exercise
sensor-based feedback or by adding fun and motivating engages users in self-regulation, such as goal setting, planning,
challenges with gamified elements [51-53]. and self-monitoring, leading to increased physical activity. The
dotted line (Figure 1) shows the feasibility testing presented in
Gamification this study.
An increasingly used approach for engaging users in the
behavior change process is gamification, which refers to using We suggest that apps that support behavior change will be more
elements from games, such as points, badges, visualizations, effective if they engage users in the behavior change process.
challenges, and surprises, in nongame contexts [54,55]. While We characterize the behavior change process with the following
motivational interviewing provides tools for motivational three steps: (1) users are autonomously motivated to be
self-reflection and thus supports the active and conscious physically active either by expecting intrinsic pleasure from the
fulfillment of psychological needs, gamification can provide activity or by remembering that the activity supports their
experiences of autonomy, competence, and relatedness by values, identity, or personally relevant goals [48]; (2) users
adding fun and excitement in the activities [52]. enact self-regulation techniques, such as goal setting, planning,
and self-monitoring [62]; and (3) users change their behavior
Evidence on gamification of behavior change interventions is (eg, walk to the supermarket instead of driving).
sporadic because of varying multidisciplinary terminology and
a lack of randomized controlled trials [56]. Some studies show We suggest that users are more likely to actively engage in the
promise in increasing user engagement [57,58], motivation behavior change process if the app addresses their basic
[58,59], and physical activity [51,60,61]. Game mechanisms psychological needs: supports their autonomy, creates a sense
might also support the use of BCTs: apps with game elements of relatedness, and provides them with experiences of
have been found to use more BCTs than health apps in general competence and self-efficacy [42]. If these needs are met, users
[56]. Despite the promise, gamification is still used relatively will have more motivation and other psychological resources
rarely [56]. to set challenging goals, make plans, and track their progress
[45].
Game elements do not necessarily require users to reflect on
their reasons for behavior, but they typically use intrinsic The psychological needs of autonomy, competence, and
motivators, such as challenges and surprises, that may provide relatedness can be satisfied in two ways. The reflective route
a spontaneous route to behavior change. For instance, users may encourages users to actively consider their capabilities,
engage in goal setting and self-monitoring of physical activity opportunities, and the benefits of the behavior (eg, think what
because of visualized goals and achievements instead of health kind of physical activity they might enjoy or what they could
targets. A successful example of this is an augmented reality achieve by being active) [63]. This self-reflection requires active
game, Pokémon GO, which did not explicitly target physical cognitive engagement with the reflection tasks. Motivational
activity but increased users’ daily steps with the game interviewing is suggested as a method for engaging users in this
mechanisms [51]. motivational self-reflection because of its focus on building a
successful working alliance and supporting engagement in
Theoretical Framework for Engaging App Users in behavior change [32]. Another pathway to engagement is
the Behavior Change Process through gamification. The spontaneous route does not require
To draw together the range of theories, approaches, and evidence active self-reflection, as the game mechanisms can satisfy the
surrounding engagement with apps for behavior change, we psychological needs and engage the user in behavior change
propose the framework depicted in Figure 1. Gamification through intrinsic motivation [52]. This framework relying on
provides intrinsic pleasure with challenges and surprises. reflective and spontaneous pathways draws from the studies by
Together, these satisfy the self-determination theory’s Hagger and Chatzisarantis and Strack and Deutsch [64,65].
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Figure 1. A proposed method for engaging users in the behavior change process. Digitalized motivational interviewing techniques help users engage
in motivational self-reflection; identify reasons, capabilities, and opportunities for physical activity; and produce change talk. Gamification provides
intrinsic pleasure with challenges and surprises. Together, these satisfy the self-determination theory’s psychological needs and support autonomous
motivation. This increased awareness of the pleasure and benefits of exercise engages users in self-regulation, such as goal setting, planning, and
self-monitoring, leading to increased physical activity. The dotted line shows the feasibility testing presented in this study.
components met their target of engaging users in the
Aims of This Study behavior change process.
This paper aimed to present the development and feasibility
testing of the physical activity–related components of the Methods
Precious smartphone app. The Methods section describes how
the theoretical framework was employed in the Precious app: Service Design
how theory and evidence were used to inform the selection of The PREventive Care Infrastructure based On Ubiquitous
app features and how motivational interviewing and Sensing (PRECIOUS) project consisted of eight European
self-regulation techniques were implemented within the app. multidisciplinary partners in social and behavioral sciences,
Furthermore, to add to the emerging literature moving beyond health psychology and psychiatry, computer science including
quantitative usage metrics and describing how digital delivery human-computer interaction, nutritional science, and sensor
affects the user experience, engagement, and intervention uptake engineering who worked together to create a digital platform
[27,29,66], we have presented a feasibility study that examines supporting physical activity, healthy nutrition, sleep hygiene,
user interactions with the app. Specifically, this feasibility study and stress management. The final design of the Precious app
sought to understand the extent to which app use engaged users was created through collaborative writing of project deliverables
in active self-reflection. and weekly design meetings with social and behavioral
scientists, computer scientists, and usability and graphic
Our hypothesis was that active cognitive engagement with the designers. The consortium reviewed relevant theory and
app content is necessary for effective commitment to the evidence on behavioral sciences, gamification [67],
behavior change process. We studied user engagement with the socioeconomic factors, and business models as requested by
motivational interviewing components focusing on two research the European Community’s Seventh Framework funding scheme
questions (RQ): [68] and created a system architecture for the overall service
RQ1: How did the users discuss autonomy support [69]. Each project partner identified the ethical and privacy
in the Precious app? This question aimed to principles related to their field of responsibility [70]. Full details
understand how users approach autonomy support on the project, including project publications, are reported [71].
in smartphone apps and if interacting with the The design of the physical activity arm of the Precious app
Precious app fulfills the psychological need for started by drafting the theoretical framework (Figure 1),
autonomy. selecting the key service elements, and inventing ways to
RQ2: What kind of change talk did the Precious app address the motivational and self-regulatory variables on a
elicit in the users, if any? This question aimed to digital platform, through an iterative process of individual and
identify whether the motivational interviewing collaborative design [72]. The systematic development of a
motivational interviewing–based computer intervention by
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Friederichs et al [73,74] served as an inspiration for the remind users how their psychological needs can be met with
motivational tools in the Precious app. The text content and physical activity. The functionalities of the Precious app are
algorithm of the user-specific tailored suggestions were written presented in detail in the following sections.
collaboratively by JN and KK and implemented by TG [75].
Relational Features
The Precious App Development All texts in the Precious app aim to evoke relatedness with the
The following sections describe the Precious app features and app, drawing from the relational techniques of motivational
how these were drawn from behavioral theories. The aim of the interviewing and aiming to build an alliance with the user (Table
Precious app is to increase users’ daily physical activity by 1, numbered with the taxonomy [33]). The motivational tools
supporting their commitment to the behavior change process: aim to create an encouraging environment open for exploration
increasing their motivation, self-reflection, self-regulation, and of options. They have been worded with the aim of
physical activity (Figure 1). We used several techniques to reach acknowledging users’ efforts and self-worth (T1.2) and
this aim. emphasizing their autonomy (T3.16). The messages aim to
normalize possible motivation deficits and failures in reaching
The Precious app addresses the following two aspects of
behavioral targets (T3.22). The tools paraphrase users’ selections
behavior change: (1) motivating individuals who may not yet
and provide reflective feedback of the selections they had made
see the need for health-enhancing physical activity and (2)
previously (T1.3). All options are presented as acceptable and
providing self-regulation techniques to help translate motivation
as a natural part of the behavior change process (T4.2). The app
into physical activity [45]. The Precious app’s tools for
aims to transmit trust by assuming that users themselves know
motivational self-reflection aim to increase autonomous
the options that are best for themselves (T4.5). All app content
motivation (eg, awareness of the personally meaningful
was written in empathetic and encouraging language, aiming
outcomes of increasing daily physical activity). The
to avoid any directive orders or judgmental feedback that could
self-reflection evoked by motivational interviewing and the
create guilt, shame, or feelings of being controlled, elements
personally relevant information on the effects of exercise from
known to predict disengagement with activity [32,42]. These
the biofeedback sensors aim to support active cognitive
relational tools and self-reflection are hypothesized to satisfy
engagement with the behavior change process.
the basic psychological needs of the self-determination theory
Increased motivation, such as joy of achieving challenges and and increase autonomous motivation [41]. Examples of the
salience of personally relevant outcomes, can help users to self-reflection tasks in each app are presented below.
commit to the use of self-regulatory BCTs [45]. Goal setting,
Table 1 presents the ways motivational interviewing features
action planning, and self-monitoring will help users to initiate
target relational aspects and service engagement.
and sustain their activity. Altogether, the Precious app aims to
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Table 1. Relational techniques from motivational interviewing implemented across the Precious app service (text in square brackets varies based on
an individual’s previously indicated preferences or previously made choices).
Techniquea Description Examples of implementation in the Precious Targeted psychological needs to increase service engage-
app ment
T1.1: open-end- Questions that cannot be “Imagine yourself being active and enjoying Open-ended questions aim to guide the user to think of
ed questions answered with a limited it. How is your life different?” reasons to increase physical activity and the positive
response (ie, yes, no, or changes that it may cause. Guiding users to imagine also
rarely) supports their autonomy to choose the activities they enjoy
T1.2: affirma- Acknowledging users’ • “Well done! First app completed!” Acknowledging efforts aims to support the users’ compe-
tions efforts and self-worth • “Good job! You achieved your daily tence and self-efficacy and create a sense of relatedness
step goal.” with the service. The users are hypothesized to return to
the service, as they feel their efforts do not go unnoticed
T1.3: reflective Paraphrasing users’ “OK. So, in other words, physical activity is Paraphrasing aims to support self-reflection and provide
statements choices (from multiple important to you because it could help you perspective on the selections the user has made. It sup-
choice answers to reflec- to achieve your [top outcome goal].” ports autonomy by valuing user-made choices and targets
tive feedback) relatedness by providing an experience of being heard
T3.16: empha- Freedom to choose out- “Earlier, you said that being physically active This technique aims to support user autonomy and suggest
size autonomy come goals, behavioral would help you to [achieve your top outcome activities that are intrinsically motivating
goals, and activities and goal]. Well, there are many different ways to
their timing be active, and some which you would enjoy
more than others. Swipe forward to ensure
you will get recommendations you like.”
T3.22: normaliz- Acknowledging that it is “Many people have difficulties recalling Normalizing is used to nurture the sense of relatedness
ing not uncommon to find times when they enjoyed being active.” through empathy and compassion, even if users indicate
behavior change challeng- no intention to be active
ing
T4.2: consider Neutral and supporting “The whole point is to support you with The neutral language used to support autonomy, compe-
change options language to consider all things that matter to you most. The more you tence, and relatedness, as users can feel that their choices
options and no guidance interact with Precious, the more accurate are accepted and supported
to specific choices these recommendations will become.“
T4.5: support Trusting users’ ability to “Based on your responses it seems that you Reminding users of their personally relevant goals may
change choose best options for think a change in your [chosen behavioral help them feel competent to execute their plans and au-
them and remind them of target] can help you to [achieve your top tonomous to choose their goals and thus increase related-
their choices outcome goal]. That's good to know! Precious ness with the service
will now help you on the path to getting more
of what you want.”
aRelational techniques from motivational interviewing as identified by Hardcastle et al [33].
software developers can add new tiles with new features without
Features Based on Self-Determination Theory modifying the original content.
The Precious app’s design draws from the qualitatively different
motivational styles of self-determination theory [48]. To address To offer experiences of competence and self-efficacy, the app
intrinsic motivation by adding pleasurable elements to physical notifies the user when approaching the daily step goal and
activity, the app was built to contain gamified challenges and celebrates achievements and service engagement with a
visualizations. Other aspects of autonomous motivation were notification. The self-regulation features in the Precious app are
targeted with tasks that evoke users’ personally important life designed to increase competence by supporting individually
goals and positive memories related to physical activity, aiming tailored goals and comparing users’ results with their previous
to remind them of factors that help them identify as an active results only (weekly average), not with other users’ results.
person or that integrate physical activity as part of their lifestyle. Instead of receiving a standard step goal, users are encouraged
to set daily step goals that slightly exceed their current step
Cross-cutting features in all app components are the average. Finally, users are encouraged to think about the good
psychological needs of the self-determination theory: autonomy, experiences they have had and might have with physical activity,
competence, and relatedness. To address the need for autonomy, hoping to remind them of times they have felt competent [75].
the basic structure of the app was chosen to consist of freely Competence is also addressed by aiming for an intuitive usability
available tiles (Figure 2). Each tile hides a specific app feature of the app functions, which has been associated with continued
or BCT. On the basis of user selections, the service recommends service use and higher experience of competence [76].
certain tiles on the top of the screen, but all tiles remain available
for the user to explore. Users are offered freedom to choose the In addition to the relational techniques (Table 1), the need for
values that guide them and the ways to achieve their outcome relatedness is addressed with personalization. The main screen
goals and to adjust their behavioral goal each day. The tiled greets users with their name, and the motivational tools specify
structure also adds flexibility for further use of the platform, as that recommendations the app provides will be based on their
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selections. To increase the relevance of the recommendations, Precious app was designed to approach the user after recognizing
algorithms of the Precious app suggest motivational elements a period of inactivity and to ask whether the user’s previous
to those who do not express interest in tracking or physical choices still seem relevant or if they would want to reconsider
activity and self-regulation techniques to those ready to act. their goals. This way the app is not imposing external
requirements to the user but, with their permission, reminding
Users proceed through the motivational tools by swiping the
them of their personally valued goals and activities [77].
screen as if turning a page in a book. The rules engine of the
Figure 2. Implementation of the Precious app home screen, with suggested apps at the top of the screen.
feel connected with other people, face challenges, and relieve
What Do I Want? stress or tension. These outcome goals set the context for further
The first motivational tool of the Precious app is called What interactions with the Precious app. This tool aims to increase
do I want? (Figure 3). It builds on the values exploration in autonomous forms of motivation by increasing the salience of
motivational interviewing and starts by suggesting a list of personally valued goals. This is done by encouraging the
outcome goals (BCT 1.3, Table 2) [78]. To address individuals reflection of desirable and beneficial things in life that may be
with low motivation for physical activity, we do not impose achieved with physical activity. This tool uses relational features
exercise- or health-related goals but also offer options such as T1.3, T3.16, T4.2, and T4.5 (Table 1).
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Figure 3. Implementation of the What Do I Want? tool. Screen B shows implementation of outcome goal selection, focusing on the things the user
wants out of life, and Screen C allows users to indicate which of these are most important to them at this moment. Screen D provides a simple reflection
on the content of the user’s chosen outcome goal and offers a menu of possible behavioral changes, which would be most likely to help them achieve
the outcome goal set on Screen C. Screen E provides a summary of the user’s interaction with this tool, highlighting their chosen outcome goal and
behavioral target.
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Table 2. Behavior change techniques in the Precious app.
Name of the feature BCTsa, b Description Targeted behavior change mechanisms
Motivational components
What do I want? 1.3 Outcome goal setting The Precious app prompts users to Selecting personally relevant outcome goals is
reflect on their life goals and to hypothesized to support autonomy and nurture
choose their preferred outcome the relatedness with the service. Thinking about
goal(s) from a list. personally important reasons to be active may
increase autonomous motivation for physical
activity.
What do I want? 1.7 Review outcome goals If a user’s engagement or activity This technique aims to support user’s relatedness
levels decrease, the Precious app with the service by empathetic concern of the
asks them to consider selecting a user and by acknowledging that the current
new outcome goal in the What do I support offered may not be optimal. Providing
want? tool. new outcome goals to choose from targets user
autonomy. Together these aim to increase moti-
vation for physical activity.
Time machine 15.2 Mental rehearsal of The Precious app asks users to visu- Mental rehearsal provides full autonomy to
successful performance alize a future event in which they choose the activity, the environment, and the
would enjoy physical activity and company. This technique can thus address auton-
prompts users to reflect on the posi- omy, competence, and relatedness and increase
tive consequences of this experi- motivation to try out the activities in real life.
ence. The user may identify new or forgotten opportu-
nities and capabilities for activity.
Time machine 15.3 Focus on past success The Precious app asks users to re- This imagination technique is targeting the psy-
flect on a past event in which they chological needs of autonomy, competence, and
enjoyed physical activity and self-efficacy, reminding users of the moments
prompts users to reflect on the posi- they enjoyed being active and thus boosting their
tive consequences of this experi- motivation. If users have good exercise memo-
ence. ries with other people, this technique may also
remind them of the sense of relatedness. The
user may identify forgotten opportunities and
capabilities for activity.
How to get there? Additional BCT: linking be- The Precious app reminds users that This technique is expected to create a mental
havioral goals with outcome their behaviors (eg, football and bond between users’ valued goals and the tangi-
goals gardening) can help them to achieve ble actions that help them achieve those goals.
their outcome goals (eg, feeling As both goals and behaviors are self-selected,
connected to others and having fun) this technique targets all three psychological
needs of autonomy, competence, self-efficacy,
and relatedness and may thus lead to increased
motivation. The tool may help identify such op-
portunities to be active that serve a purpose
Smartphone notifications 10.4 [Digital] Social reward The Precious app delivers smart- Supportive but accurate feedback aims to in-
and biofeedback report phone notifications with positive crease users’ competence, self-efficacy, and re-
messages based on tracked service latedness with the service, which again should
engagement or activity. Biofeedback increase motivation to take care of their well-
reports include praise and encourage- being
ment for progress.
Self-regulation techniques
Mountain climber 1.1 Behavioral goal setting The Precious app allows users to set This self-regulation technique targets users’ au-
a daily step goal. To set a realistic tonomy by letting them adjust their daily goals.
goal, users see a suggestion of their Basing goal recommendations on each user’s
past 7-day average as a starting step average takes into account their capabilities
point. and aims to increase competence and self-effica-
cy. Users can consider their opportunities to be
active on the day while setting a goal.
Mountain climber 1.4 Action planning The Precious app allows users to Users’ autonomy is supported as they can choose
plan bouts of physical activity, in- any physical activities and be supported in
cluding activity type, intensity, and completing those. Making plans with the tool
time of day. Users then receive noti- can remind users of their capabilities and oppor-
fications when their planned activity tunities for activity as they see the list of activi-
is approaching. ties they like.
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Name of the feature BCTsa, b Description Targeted behavior change mechanisms
Mountain climber 1.5 Review behavior goal(s) When opening the Mountain Seeing their past behavior visualized as moun-
climber tool, users can review their tain panorama and achievements as flags on top
previously set goals, the extent to of the mountains may help to celebrate success-
which those were achieved, and ad- ful goal achievement, increasing competence,
just the goal for the current day. self-efficacy, and awareness of capability. Users
can change the daily goal anytime, which targets
autonomy.
Smartphone notifications 1.6 Discrepancy between The Mountain climber tool shows Getting a reminder of goal progress may increase
current behavior and goal in real time how many steps the user the sense of competence and self-efficacy in case
has taken and how far they are from users have already achieved their goal or they
their daily step goal. The user also feel they can complete the remaining activity
receives messages on the percentage during the evening. Seeing the difference be-
of steps that they have accomplished tween their goal and current situation may create
by afternoon. an intrinsically motivated challenge to achieve
the goal.
Smartphone notifications 2.2 Feedback on behavior The Precious app sends a notifica- Supportively worded messages about goal
tion about progress toward user’s progress can increase relatedness to the service
step goal and goal achievement. and sense of competence and self-efficacy if the
goal seems achievable.
Activity bracelet 2.3 Self-monitoring of behav- The Mountain climber app displays Aggregating activities from several sources can
ior the number of steps a user has accu- help users understand how all activity con-
mulated each day. This step total tributes to the daily total and that all occasions
aggregates steps logged by the activ- to be active count. This, in addition to visualiza-
ity bracelet, the phone’s onboard tion of their activity as a mountain panorama
accelerometer, and manually logged and achievements as flags on top of the moun-
activities. Users are asked to manu- tains, may help to celebrate their efforts, increas-
ally log other activities than walk- ing competence and self-efficacy. Seeing activi-
ing, running, and cycling (which are ties visualized as mountains to conquer may in-
automatically tracked). Action plans crease intrinsic motivation to use the tool.
made with the tool can be marked
completed with a single tap.
aBCT: behavior change technique.
bBehavior change technique numbering based on the study by Michie et al [8].
to think of reasons that would make physical activity matter to
Importance Ruler them. This reflection task is followed by a reminder of their
A technique taken directly from motivational interviewing, previously chosen outcome goals. The purpose of this is to help
Importance ruler, first asks users how important they perceive the user to create a mental link between physical activity and
physical activity on a scale of 1 to 10 (Figure 4) and then, their personally valued goals. Depending on user selections,
depending on the answer, follows with an affirmation and asks this tool uses relational features T1.2, T1.3, T3.16, T3.22, T4.2,
why the user did not choose a lower number. The user is guided and T4.5 (Table 1).
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Figure 4. Implementation of the Importance ruler tool. Screen A shows the importance ruler itself. Screen B shows a follow-up question from the
individual’s initial response and a prompt to help users better introspect about why they chose a particular number on Screen A. Screen C shows a
selection of possible positive outcomes of physical activity, populated from the choices made previously in the What Do I Want? tool. Screen D shows
a reflection of the user’s chosen responses on Screen C.
expresses intentions to start or maintain activity, the main screen
What's Next? will suggest goal setting, action planning, activity logging, and
This tool aimed to assess users’ motivation and activity status gamified challenges (Figure 5). Independent of user’s selections,
(stage of change [77]) to tailor the recommendations on the this tool aims to acknowledge users’ efforts and self-worth by
home screen (Figure 2) [75]. Indicating low motivation and using empathetic language. This tool includes relational features
intention for physical activity leads to features based on T1.2, T1.3, T3.16, T3.22, T4.2, and T4.5 (Table 1).
motivational interviewing and gamified challenges. If the user
Figure 5. What’s Next tool. This tool assessed a user’s stage of change for physical activity and directed users to either motivational or self-regulatory
features based on their responses.
and/or might like to try in the future (Figure 6). This offers them
My Favorites a freedom of choice, may evoke positive memories of exercising
To acknowledge users’ efforts and self-worth, users are asked while going through the list of options, may present
to choose physical activities that they have enjoyed in the past
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opportunities for activities that the user was not thinking as implemented with a simple tiled structure that shows all
physical activity (eg, gardening), and populates the database activities simultaneously and allows adding and removing them
with options that may be used for later reminders, thus offering with one touch. The app was not finalized by the time of
an experience of personalization. The chosen activities are also feasibility testing. The My favorites tool uses relational features
shown as the first suggestions in the self-regulation tool to T1.2, T3.16, T4.2, and T4.5 (Table 1).
improve the user experience. The My favorites tool was
Figure 6. Implementation of the My Favorites tool, in which users choose the modes of PA that they might like to undertake. The prompt on Screen
A recalls the outcome goal the user set in the What do I want? tool.
the user to be more confident in their ability to be physically
Confidence Ruler active. The answer options consist of all the tools that the
The Confidence ruler tool implements a core technique of Precious app has to offer and a rationale for their use (Figure
motivational interviewing and starts with the question “How 7). This tool aims to acknowledge users’ efforts and self-worth
confident are you that you could be physically active on a (T1.2) and, depending on the user’s selections, uses relational
regular basis?” It then provides feedback on user choices and features T1.2, T1.3, T3.16, T3.22, T4.2, and T4.5 (Table 1).
leads to asking which of the app’s available tools could help
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Figure 7. Implementation of the Confidence Ruler tool. Screen A shows the main question of this tool, which is followed up with a tailored reflection
on Screen B. Screens C and D show a number of the tools available to users and the rationale for how each could help improve their confidence. Users
were free to select as many or as few of these as they wished.
in increasing intention to be physically active in a recent
Time Machine meta-analysis [21]. To create a gamified, machine-like
The Time machine tool aims to boost motivation, a sense of experience, the app first asks whether a user has any positive
competence, and self-efficacy by evoking users’ positive experiences and then the year the user wants to be sent to. This
exercise memories and helping them to create vivid images of is followed with detailed questions about their experience that
successfully engaging in physical activity and enjoying it aim to acknowledge users’ efforts and self-worth (Figure 8).
(BCT15.2 and BCT15.3, Table 2). A mental rehearsal of a This tool uses relational features T1.2, T3.16, and T4.2 (Table
successful performance was found to be the most effective BCT 1).
Figure 8. Implementation of the Time Machine tool. Looking back exercises are shown on Screens B and C, and looking forward exercises are shown
on Screen D.
rationale for doing physical activity. This tool was not finalized
How to Get There? by the feasibility testing.
The aim of this tool is to strengthen the mental link between
users’ outcome goals and the specific actions that help them Biofeedback
achieve it. This tool is suggested after completing the values We integrated Firstbeat’s (Firstbeat Technologies) heart rate
exploration in What do I want? and selecting favorite physical variability sensor, Bodyguard 2, to the Precious app to offer the
activities in My favorites. The task is to select those activities users the possibility to receive feedback on their physiological
that take the users closer to their outcome goal. For instance, if stress, recovery, and sleep quality (Figure 9) [79]. The feedback
the user has chosen the outcome goal feel socially connected, consists of graphs showing users’ activity levels in colored bars
the next step is to scroll through their favorite activities and and interpretations of these bars telling the user whether their
choose the ones that allow them to connect socially (Multimedia levels of activity and recovery have been health enhancing.
Appendix 1). This feature helps the users to build a personal Encouraging messages congratulate the users or support them
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to keep up their efforts. Users can access the reports in the link between their behavior and desired outcomes could
Precious app behind a tile picturing the Firstbeat sensor after strengthen their autonomous motivation. The feedback aims to
downloading the sensor data to the internet via a computer with acknowledge users’ efforts and self-worth by congratulating
a USB port. The aim of the biofeedback tool is to remind users them for physical activity, good sleep quality, and recovery.
that their behaviors have both immediate and long-term The biofeedback report uses relational features T1.2, T3.22,
consequences on their well-being. Strengthening this mental and T4.5 (Table 1).
Figure 9. Example view of Firstbeat heart rate variability report for Precious.
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Gamified Elements sense of competence and self-efficacy by showing visible cues
In addition to the gamified features of the Mountain Climber of progress and listing all the actions taken on the way to an
self-regulation tool, other components were also envisaged to active life. The changing landscape may motivate users to
help foster intrinsic motivation for using the Precious app [52]. complete actions to progress into new levels (Multimedia
These components were all built into working prototypes but Appendix 2).
only after the completion of feasibility tests that were undertaken Conquer the City
with the app components described earlier.
A location-based activity game was designed to create
The Journey entertaining challenges, tasks, and competition that would make
Swiping left in the main menu reveals the user their journey, a walking intrinsically enjoyable. The aim of the game is to
map of achievements. Completing the motivational tasks and conquer areas on the map by walking around them and by
activity challenges creates a badge on a background of changing collaborating and competing with other app users. This addresses
landscapes. All actions accumulate points, with less points the psychological needs of relatedness and adds an element of
obtained from app use and more points, from sustained streaks excitement and fun for those who enjoy competition [80,81].
in physical activity. Journey’s main function is to increase the Users could also challenge themselves, trying to conquer new
areas or specific targets on the map (Figure 10).
Figure 10. Conquer the city, location-based activity game.
(mountain) and visual rewards for goal achievement
The Precious App Development: Self-Regulatory Tools (illustrations of mountain life) that appear randomly after
The purpose of the self-regulation tool is to give users a clear successful goal achievement (by the time of the feasibility
picture of their current activity level and how that compares testing, only a flag on top of the mountain and a changing color
with their target level (self-monitoring, BCT 2.3; discrepancy were implemented). Mountain was considered a representation
between current behavior and goal, BCT 1.6, Table 2 [8]) and of daily achievement that would be easily understandable for
guide them to set daily, realistic, and achievable activity goals every user and that would add symbolic meaning to the
(BCT 1.1). The planning tool was created for creating detailed accumulating steps. Goal setting was done by scrolling a digital
activity plans (BCT 1.4) and logging of activities that were button on the screen and choosing a certain step goal for the
performed while not wearing an activity bracelet (BCT 2.3). To day. The goal setting tool was set to display the mean of the
make these techniques intuitively usable, we created a graphical past 7 days’ steps when opening the Mountain climber. This
interface that aggregates all the activity the users have was designed to educate users of their typical step amount to
accumulated during the day, their daily goal achievement, and encourage reflection of how much activity could be embedded
their progress over time. in the day ahead. Late afternoon, users receive feedback in a
Mountain Climber Self-Regulation Tool message providing the percentage of the daily step goal they
have achieved to adapt their evening activities and accumulate
These requirements lead to the development of Mountain the missing steps. Consecutive usage days create a panoramic
climber (Figure 11), designed with game-like features, with the view of user’s physical activity, showing possible increases or
aim of increasing user engagement in self-regulation. These decreases over time and reminding them of their achievements.
include the graphical presentation of the accumulated steps
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Figure 11. Implementation of the Mountain Climber self-regulatory tool. Screen A shows the main view, with blue mountain indicating an achieved
goal. (Green tags on Screen A were not visible to users and are included here to indicate the destination screen after a tap action.) Screen B shows the
step goal setting function. Screen C shows the action planning function. Action planning and logging are done by choosing an activity from a dropdown
menu and setting the start and end time. The user can also adjust the intensity of the activity to either low, medium, or high, the default being medium.
For ease of use, action planning is done in the same way as activity logging, with only the time being set in the future. The visual symbol of the planned
activity appears in dim grey color, and the steps contribute to the daily total only after the user touches the button “I did it!”. Screens D and E show a
detailed daily view, with planned activities in grey and completed activities in orange, indicating how many percentages of the daily goal is reached
with the activity.
(API). This allowed for identification of steps taken as well as
Physical Activity Measurement minutes spent walking, running, cycling, traveling in a vehicle
Within the Precious app, physical activity data are accumulated or being sedentary. This source of physical activity data was
from three separate sources, which the app aggregates to a single used in periods where the app was unable to communicate with
step count for each day. Steps per day were chosen as the the activity bracelet, and no physical activities had been
common metric for presenting physical activity data, as it is manually entered.
readily interpretable and allows for direct comparisons from
day to day within an individual. To address the socioeconomic When amalgamating data from various sources, users’ manually
challenges related to the use of digital services [82], the Precious entered activities were given the highest priority. Any step
app was built as a stand-alone smartphone app, signifying that counts received from the Mi Band or onboard accelerometer
anyone with an affordable smartphone could use the service that had timestamps that overlapped with the timestamps of
without accessories [83]. For increased physical activity data manually entered activities were not added to an individual’s
accuracy, the app can also be connected to external monitoring total. Steps obtained from the Mi Band were given the second
devices through Bluetooth. For pilot testing of the Precious app, highest priority. Steps obtained from Google Play Services
the primary source of physical activity data was a wrist-worn Fitness API were given the lowest priority and were only added
activity bracelet (Xiaomi Mi Band 1S Pulse Bluetooth 4.0 IP67 to an individual’s total in periods in which the Mi Band had not
Waterproof Smart Bracelet) [84]. Step counts from the activity recorded any new step count activity. The aggregation of these
bracelet were passed to the app via low-energy Bluetooth at three data sources was presented to users in real time, which
regular 10-min intervals when a connection with the app could offers users a comprehensive and realistic picture of how their
be established. steps accumulate during the day, how different activities
contribute to the whole activity, and how their activity varies
As users of the Precious app may not always wear their activity daily.
bracelet, and as some activities (eg, cycling and weightlifting)
are not accurately recorded by wrist-worn accelerometers, users Feasibility Testing
can also manually log their activities. The Mountain climber Participants
tool allows users to select a physical activity from a list and to
specify the time and intensity of this activity. Knowing a user’s The interviewers recruited a convenience sample of 12 adults
height and weight, the Precious app converts the activity to living in two different Finnish regions, with diverse educational
steps using metabolic equivalent (MET) values and the backgrounds (three without any university studies and one with
following equation [85,86]: a doctoral degree) and ages ranging from 25 to 63 years. Of 12
participants, 8 were women and 4 were men, both genders
Steps/minute for activity = (MET value of activity ranging from physically inactive to highly active. Participants
×112.5)/3.5 had different levels of experience with smartphone apps, ranging
As a final source of physical activity data, the Precious app used from active sport app users to participants without a smartphone.
data collected from the phone’s onboard accelerometer and the With think-aloud studies, five participants are deemed sufficient
Google Play Services Fitness application programming interface for detecting most usability problems [87,88]. To assess the
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feasibility of the digitalized motivational features, we recruited with the service. These questions were mainly used for the
the maximum number of participants who could be interviewed technical usability analyses not presented in this study.
within the project time limits, increasing the participant number Interviews and think-aloud walk-throughs as well as
to 12. participants’ on-screen interactions with the app were video
recorded. Interview recordings were transcribed verbatim by a
Overall, two participants (P6 and P7) agreed to participate only
research assistant and a trainee. User actions such as tapping
in a think-aloud study of the biofeedback report and were thus
and swiping the screen were also transcribed, as the analysis of
excluded from the current analyses (participant details are in
user engagement included all interactions with the app.
Multimedia Appendix 3). The Precious app study received a
favorable decision from the University of Helsinki Ethical Analysis
Review Board in the Humanities and Social and Behavioural Transcripts for each participant from think-aloud and
Sciences in January 2016. The project also addressed ethics and semistructured interviews were analyzed with a deductive,
privacy in yearly reports to the European Commission. theory-based thematic analysis, informed by Braun and Clarke’s
Participants were interviewed in person by a research group phases of thematic analysis [91], used previously to analyze
member (PhD researcher or intern) in June 2016 at a location think-aloud studies of smartphone use [92,93]. The method
that was convenient for them (office, home, or university lobby) allows for the essential content of the interviews to be captured
and were rewarded with a movie ticket. Inclusion criteria were in themes that describe the data patterns in a summarized form
written informed consent, aged at least 18 years, sufficient [91]. First, we analyzed data from each participant individually
language skills to use the English language app, and to conduct to remain sensitive to their experience and to detect possible
the interview in Finnish or English. differing themes between participants. Second, themes were
Procedure synthesized from each participant into a general set of themes.
Discussions between three researchers (JN, KK, and AH) led
After providing informed consent, participants were provided
to agreement on the primary themes.
with a smartphone with the Precious app and a screen recording
program, AZ Screen Recorder, and were asked to practice the The theory-driven RQs on change talk (motivational
think-aloud method with the smartphone’s other preinstalled interviewing) and autonomy support (self-determination theory)
apps (eg, alarm clock and address book) until they were speaking were analyzed with a deductive approach, aiming to identify
continuously, describing everything they saw, thought, or did any passages that fit these theoretically defined constructs [91].
with the app [89]. Participants were then instructed to use the Change talk and sustain talk (counter-change talk) were coded
Precious app just as they would any other app they had just following the guidelines of the CLEAR (Client Language EAsy
downloaded and to think aloud while doing so [89]. Participants Rating) coding system [94]. Following the CLEAR guidelines,
were also requested to ask any questions that came to mind as any factual information of existing behavior was not coded as
they explored the app (eg, where they should tap or what does change talk (eg, “I walk to work every day”), and choices made
a certain button do), as such questions could help us better at the ruler tasks were coded as change talk only if there were
understand user experiences [89]. Participants could freely confirmatory comments [95]. The excerpts on change talk and
interact with the Precious app until all content had been explored autonomy support were analyzed with their semantic meaning,
(usually around 30 min, including the dietary features not assuming a unidirectional relationship between meaning and
presented in this study), and during this time, if a participant experience and language [91]. After identifying all the change
stopped thinking aloud or passed several features without talk–related passages, these excerpts were then coded as specific
commenting on them, the interviewer prompted them by asking subtypes of change talk (ie, theory-driven themes) [91]. Finally,
what they were thinking. After the think-aloud study, to optimize the usefulness of the results for the reader, all data
participants were briefly interviewed about their physical activity excerpts on change talk, marked with the theme they
levels and previous experiences with smartphone apps. represented, were organized and summarized under the
respective app functions. Presenting change talk under specific
Measures app functions allows the reader to evaluate the tools and
To assess participants’ physical activity levels, we used a techniques that can be reproduced elsewhere, as suggested by
validated single-item question, “On a typical week, on how O’Halloran et al [36].
many days do you do a total of 30 minutes or more of physical
activity, which was enough to raise your breathing rate. This Results
may include sport, exercise, and brisk walking or cycling for
recreation or to get to and from places but should not include Feasibility
housework or physical activity that may be part of your job” The feasibility analysis on participants’ engagement with the
[90]. Precious app answered the following two RQs: (1) how
Think-aloud walkthrough interviews were followed by a participants discussed autonomy support during the think-aloud
semistructured interview with open-ended questions on walkthrough and the end interview and (2) what kind of change
participants’ previous experience with mobile apps, general talk did the Precious app elicit in the users during the
perceptions of the Precious app and its most/least useful features, walk-throughs.
suggestions for improvement and usage, possible features that
could exclude potential users, and factors related to engagement
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Research Question 1: Perceived Autonomy Support very difficult. And when you need to click and...really
During Interactions With the Precious App self-evident stuff can become a threshold, but I don’t
We identified the following themes around the original, know for how difficult population you are aiming this.
theory-based theme autonomy support: valuing the chance to [P10]
choose, autonomy supportive feedback, expecting controlling Autonomy Supportive Feedback
features, concern about lack of autonomy, and autonomous In addition to freedom of choice and tailoring, participants
goals. wished to receive encouragement and praise and mentioned that
Valuing the Chance to Choose the tone of interaction is important:
Consistent with the self-determination theory, participants Although [another sport app] it’s just an app, but it
valued autonomy supportive features, especially the chance to says something like “now you’ve missed your training
personalize the content and make selections: session,” it makes me feel somehow bad. So probably
It is good that this background information is added you should pay attention to that, how the feedback is.
there so that it’s not like the same for everyone. [P4]
Absolutely, it’s good to have it, so that you can Expecting Controlling Features
influence it yourself. [P8] The interviews revealed that participants were used to apps that
The chance to choose was especially relevant for the prescribed specific goals or activities. They assumed that the
self-regulation features, as participants appreciated the app would tell them, for instance, how much activity they are
possibility to adjust the daily step goal and consider the day expected to do:
ahead:
P12: Here it’s like 36 percent. 36% of what? Like...
So, every day you can set the goal. But that sounds I: Yeah, that’s not clear?
smart. Maybe a bit smarter than what I have in use,
where there’s for every day that...I think it has 10 000 P12: [Taps 36% circle. Nothing happens]
the...Or you can’t set a goal, they think that 10 000 P12: Probably like how much should I walk or
is the recommendation...I think this is smarter that something.
you can also...if, like, you know that this day will These expectations were based on their previous experiences
be...that maybe there’s not so much walking, so... [P4] with apps that provided less autonomy support:
A participant with low levels of activity thought she would take This is slightly different than what I’ve previously
advantage of the ability to set personal step goals to make sure used of these health apps. Usually, very first question
she would achieve them: is height and weight and target weight. That’s the
I guess I’d probably put, if you could put, beforehand most common. But well, this seems good...or like good
the goals, so, I’d probably put so… maybe even so that it’s not always necessarily the weight loss.
lower? So that they would be really, like, achievable That usually those apps have weight loss as default...
and probably I would achieve them. [P11] [P4]
The number of personalization options was generally found to Concern About Lack of Autonomy
be reasonable, and users found options that pleased them.
In addition to expecting health apps to be controlling,
However, overall, two participants felt that the list of 20
participants also expressed concern about this lack of autonomy,
outcome goals had too many options to choose from:
for instance, that their early choices would tunnel them into
I: What are you thinking? unwanted recommendations later:
P9: Just that there’s a lot of options again, there was And then, choosing “stay healthy” brings to my mind
four a moment ago and now there’s like forty...already immediately that now [Precious] will suggest to “take
reading these, now that it’s a busy situation...well at long walks” and “do yoga” and all these healthy
least, I’ll tick some of these. activities, while I don’t like that at all. So, it instantly
P5: [chooses Feel more healthy] Yeah, there were brings to my mind those stereotypes that this kind of
too many. And again, you can choose so many healthy activity includes. Which you might not want
different ones. yourself- although I choose this “Stay healthy,” I
When asked if the service would exclude any user groups, one think however if I should have put some “Face
participant saw the number of options as too high for elderly challenges” so that I will get some fun to the activity.
people: [P9]
How is it programmed then [to provide
Then if the idea was that this is for elderly people,
suggestions]...Does it affect a lot if you choose the
then it might be a problem that there’s so much of
wrong one of the two [goals]...[P8]
everything. This might be like a shock, or at least I
remember when I’ve tried to teach my grand-parents One participant experienced the question about his intention to
Internet and computer use, and just when you open be active as expectations set on him (What’s next tool) as
the screen and there’s a lot of small icons, it’s often expectations set on him rather than being tailored:
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This here thinks I’d need to change the level of how he actively reflects what the options would mean in his
physical activity, I personally thought about it more life, first rejecting several options, but then finding suitable
like...that it’s just one central aspect...I didn’t see I goals:
would somehow need to change it. [P10]
Do I want to “face challenges.” Well I don’t know
Autonomous Goals what these challenges mean here so it is a bit...maybe
Most users made selections that could be identified as it has something to do with sports then. Not in
autonomously motivated outcome goals, wanting to achieve general, I don’t have that feeling that I would like to
health, well-being, fun, and challenges with physical activity face challenges...“More fun...,” I am quite satisfied
instead of aiming for external goals. Several participants with my level of fun at the moment, and I don’t feel
reflected about the importance of different types of goals: that I would need to lose weight either, and staying
healthy isn’t...well, it is good, of course. Let’s put that
P9: I am very stiff, I should probably put that [“feel [selects “Stay healthy”]. “Functional abilities,” that
more flexible”] but I don’t really care about that I is also a good thing. [Selects “Maintain my functional
am stiff. [Chooses “Increase my stamina”] ability”]. (Change talk—reason) [P10]
I: So, you took into account that it asks what you want Participants also actively expressed need type of change talk,
P9: Yeah...Probably it would be good to be a bit more mainly when reflecting on which outcome goal options would
flexible...And I should lose some weight but that’s not be most relevant for them:
such a top thing for me...Would it be good to choose P9: [selects “Improve my general mood”] This is just
four? what I need, to get out for a run or to be alone. - -
I: Yeah, is it unclear whether you need to choose? P9: Health is the most important. [Chooses the option
P9: No, it isn’t, no you don’t need to but...Well, there “Maintain my functional ability” and “Stay healthy”]
are that kind of options that I could choose from. [chooses Physical activity as the behavioral strategy].
[Chooses the option “Relieve stress or tension”] (Change talk—need, reason)
P9: Health is the most important. [Chooses the Although all participants engaged in the selection process and
options “Maintain my functional ability” and “Stay found four options that were suitable for them, not all of them
healthy”] actively voiced aloud the rationales behind their choices. Their
Research Question 2: Change Talk Elicited During talk consisted partly of the selections they made. We call this
Interactions With the Precious App implicit change talk:
We examined whether and how app usage encourages [Opens What do I want? tool] Hmm. So, I can put
self-reflection by observing the occurrence of change talk. only one or then maximum four options here. [Selects
Within the theoretical framework of motivational interviewing “become more flexible” as an outcome goal] Okay,
and the original theme of change talk, we identified the this is good. I become less...okay that’s it. Hmm.
following themes: desire, need, reason, ability, commitment, (Implicit change talk—reason) [P12]
taking steps toward change, sustain talk, and ambivalence. With Presenting possible outcome goals as a list may not only be a
this method, we aimed to analyze the feasibility of digitalized positive resource for users. A couple of participants voiced
motivational interviewing features, and not users’ views on sustain talk when arguing against a decision to choose certain
behavior change. Thus, to support replication and further outcome goals:
development of digitalized motivational interviewing, the need P9: I am very stiff, I should probably put that [“feel
identified in a systematic review [37], examples of the themes more flexible”] but I don’t really care about being
are presented under specific tools. stiff. (sustain talk—reason not to change) [Chooses
What Do I Want? Tool “Increase my stamina”] (Implicit change
The What do I want? tool prompts users to select outcome goals talk—desire)
that matter to them and to select behaviors that help them I: So, you took into account that it asks what you want
approach those goals. During think-aloud walk-throughs, all P9: Yeah...Probably it would be good to be a bit more
participants actively engaged in selecting options that were flexible...And I should lose some weight but that’s not
relevant to them and most of them expressed some form of such a top thing for me...(need change talk and
change talk. The change talk produced was mainly of the desire ambivalence)
and reason type [32], as, implicitly, these occurred each time Would it be good to choose four?
a participant made a selection of the things that they would want
out of life: I: Yeah, is it unclear whether you need to choose?
P9: No, it isn’t, no you don’t need to but...Well, there
Hmm [reads options] maybe, maybe, maybe not, yeah are that kind of options that I could choose from.
quite nice. Well maybe, I want at least to be stronger. [Chooses the option “Relieve stress or tension”]
(Change talk—desire) [P2]
P9: Health is the most important. [Chooses the
The list of outcome goals seemed to help some participants to options “Maintain my functional ability” and “Stay
find reasons for activity. A quote from participant 10 shows healthy”]. (Change talk—need)
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Participants reflected their actual needs in relation to their Well...I don’t know, I just find [physical activity] fun.
current life situation: It is important to me to stay in good shape so that I
have energy to do things in life and so on. (change
The program asks, which of these [outcome goals] is
talk—need)Also, maybe I compare myself to other
most important, but it’s hard to give weight to one or
people. Like, how important [physical activity] is to
the other.. On different moments, different things are
me compared to my pals. They don’t care if they can’t
important, but it asks what would be most important
go for a run every now and then or if they move, but
right now...Removing stress [selects “Relieve stress
I become a bag of nerves. It starts to feel like you get
or tension”]. (Change talk—need). [P3]
mad from everything (change talk—need) so, that
Sometimes participants did not express change talk kind of thoughts. [P9]
spontaneously, but they appeared to have thought about the
Participant 8 saw himself as a less active person than his wife,
responses when asked:
which affected his selections and elicited some sustain talk:
P3: So, let’s see what is in there...So the program
When I think of my wife when she always says that
wants to find out what I really want, and...now I’m
she will feel bad if she can’t go for a run, well, I am
thinking what it asked.
not at all like that. (sustain talk—reason not to
I: So, what are you thinking? change) [P8]
P3: So, sharing happy moments, adventures, being
in the nature, doing successful things. (Change Confidence Ruler Tool
talk—desire). The Confidence ruler tool asks about participants’ confidence
to be physically active and offers options to increase the
Importance Ruler Tool confidence (Figure 7). It was tested by only two participants
All participants were happy to select a number describing their because of late implementation. Both reacted in a way
perception of the importance of physical activity, but as the app corresponding to their physical activity status: the highly active
did not require text input, they swiped through the pages at a participant was feeling confident and expressed ability to
relatively fast pace. Only a few participants reflected aloud their change:
choices spontaneously, but almost all provided reasons for the
[reading the question on the screen] How confident
importance of physical activity when asked what they were
am I with physical activity...Well, let’s say that I’m
thinking. We identified the themes desire, need, reason, and
quite sure I could be regularly [active], let’s put for
sustain talk from interactions with the importance ruler:
instance 9. (Change talk—ability) [P10]
P1: [moves the pointer from 7 to 4] An inactive participant expressed a need to increase activity:
I: So, tell now, like, what you think or see?
I guess...I am not that active, so I feel like there’s
P1: [moves the pointer from 4 to 7 and from 7 to 8] much to improve. (Change talk—need) [P11]
P1: I think that [physical activity] is important While exploring the suggested BCTs in the Confidence ruler,
I: Mm? participant 10 mentioned that a detailed plan might help him
P1: Do I need to think about something else? [swipes increase physical activity.
forward] I guess not. I’ve been thinking for a second. Ok, now this asks what would help me in this...Again,
[swipes forward] this suggests remembering...So, it’s kind of asking me
P1: Because of course I wanted to be more active. these, ok...I wonder if it has automatically chosen me
[swipes to the next screen, sees the preselected option that one or if I have accidentally touched it myself.
’relieve stress or tension’]. Yeah, that’s alright. Some accurate plan could maybe [help me to increase
(Change talk, desire) physical activity] [selects the option Having a detailed
P3: That it [physical activity] just keeps me active. activity plan] (Change talk—ability). [P10]
It makes me feel healthy. So, in this question “physical What’s Next? Tool
activity would most help me to...” I would answer the
button that was already selected, that it relieves stress The What’s next? Tool assesses users’ current levels of physical
and tension. (Change talk—need) activity and intentions to be active to tailor further suggestions.
The two participants testing the tool actively engaged, making
P9: So, I would want to choose immediately all of the selections that were relevant for them. An inactive user
them [four user’s favorite outcome goals displayed], expressed the desire to increase activity:
maybe least this “have fun”? Although it’s [physical
activity is] very important to me and it’s fun for me. [reads the question “Regardless of how active you
But still, I’d see that if you need to think of health, are now, how do you feel about becoming more
then all these three others. (Change talk—reason) physically active?”] Well I absolutely would want!
[selects “I definitely want to be more active”].
Some participants chose the number by comparing themselves (Change talk—desire) [P11]
to their peers. Participant 9 had observed how the lack of activity
has a different impact on her than on others:
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A physically active user did not see a need to increase his
activity levels and, understandably, expressed sustain talk and Discussion
ambivalence: Principal Findings
This here thinks I’d need to change the level of This study presented the development and feasibility testing of
physical activity, I personally thought about it more the Precious app, which aims to engage users in the behavior
like...that it’s just one central aspect...I didn’t see I change process with relational techniques from motivational
would somehow need to change it. (Sustain interviewing and gamified self-regulation. The feasibility study
talk—reason not to change)...Let’s say that I have an found that interaction with digitalized motivational interviewing
ambivalent feeling, do I want to be more physically features helped participants reflect their personally valuable
active. (Ambivalence) [P10] goals, needs, desires, and reasons for physical activity.
Time Machine Tool Autonomy supporting features were typically found to be
important, although some participants criticized the number of
The Time machine tool suggested imagination tasks available options and some expressed concerns about being
of pleasurable physical activity in the past or in the profiled and possibly receiving the wrong types of suggestions.
future. It was tested by only two users, and no change In this section, we will discuss the theoretical framework behind
talk was coded from their interviews. the Precious app and the results of the feasibility study on user
Mountain Climber Self-Regulation Tool engagement in behavior change.
As opposed to the needs- and reasons-based change talk while Theory- and Evidence-Based Development of the
using the motivational interviewing features, the change talk Precious App
produced by the Mountain climber tool was commitment to the We developed the Precious app using a theoretical framework
behavior change process and taking steps toward change. (Figure 1), which hypothesized that digitalized elements from
Participants used different Precious app tools in a random order, motivational interviewing [32] and gamified elements [54]
so this difference does not reflect the time spent using the app. would help to satisfy the basic psychological needs of autonomy,
Participants saw the logging tool as a learning instrument and competence, and relatedness, as suggested by the
logging future activities as a commitment that might help them self-determination theory [41,52]. This novel method of
reach their goals. Participant 11 describes how she would learn combining reflective and spontaneous approaches with
about her activity levels while using the logging tool and could motivation and self-regulation has several strengths. This app
then increase her step goals: addresses users with qualitatively different motivation for
physical activity and offers support for both reflection of
Yes I believe I could even go and do [the planning], autonomously motivating goals and intrinsically motivating,
and I find it nice that I could add the goals for the spontaneous activities. Tailored suggestions provided to users
next day, and then in the evening, add how I moved are based on goals, activities, and motivational stages that users
that day and then see whether it happened, and then have indicated, offering different content to different individuals.
add for the next day...then I would know if the goals
were low but I moved much more, the steps just Digitalized motivational interviewing for physical activity has
appear, just like that, then for the next day I could not been previously implemented for smartphones [37], although
put a bit higher. (Change talk—taking steps toward the need for motivational elements in health apps is recognized
change) [P11] [40]. As acknowledged by participants, the Precious app differs
Participant 12 realized that adding the activity in the Precious from most available health apps, as it does not prescribe goals
app makes it more likely that she will do the activity the next or behaviors. The choice of exercise as a behavioral strategy
day: (instead of healthy diet, stress management, or sleep hygiene)
is made only after a user has decided to aim for an outcome
P12: [Selects an activity] goal that can be achieved through physical activity (Figure 3).
P12: If I already do it [the logging] now, then I have The relational features such as empathy, normalization, and
to go there tomorrow in the morning. That’s actually affirmations may build a safe environment for change that would
quite good. (Change talk—commitment) not be experienced with standard tracking features alone.
Self-regulation features also received some criticism. Participant The Precious app’s digitalized motivational interviewing
9 expressed sustain change talk on self-regulation, as he thought features were implemented as seven question-based tools using
he is not organized enough to do planning: seven relational techniques. These relational and motivational
I: The meaning is that it could be used for planning, features were hypothesized to increase users’ engagement in
do you think it would work like that? the behavior change process by increasing relatedness to the
app and facilitating self-reflection and the use of self-regulatory
P9: Ooh, not me at least, I’m so bad at planning BCTs [9], which could help individuals increase
anything in advance that I wouldn’t...(Sustain health-enhancing physical activity.
talk—ability not to change) Maybe it could? Maybe
it could be used as such. Certainly, if I were a bit High intrinsic motivation is the best predictor of sustained
more organized person. (Ambivalence) physical activity [44], but not everyone finds physical activity
enjoyable as such. Game-based elements can add intrinsically
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motivating elements to the activity, such as exploring new areas Research Question 2: What kind of change talk did the
with the Conquer the city feature or keeping daily steps up to Precious app elicit in the users?
create a panorama of high mountains with the Mountain climber Participants engaged actively with the app during the think-aloud
tool. interviews, making selections and reflecting their choices in
Control theory–related self-regulatory BCTs were implemented relation to their values and current life situation. They expressed
as a Mountain climber tool that uses gamification principles to a wide range of change talk: mainly desire, reason, and need,
increase intrinsic motivation for BCT use. The self-regulatory when using the motivational interviewing features, and
BCTs included daily physical activity goal setting, reviewing commitment and taking steps toward change, when using the
behavioral goals, making action plans, self-monitoring, receiving Mountain climber tool. Considering participants’ varying levels
feedback on behavior, perceiving the discrepancy between the of motivation and activity, it is promising that change talk was
current behavior and goal, and prompts to complete the daily identified across the full sample. There were very few occasions
step goal. These self-regulatory BCTs have been found to of sustain talk and ambivalence. This may be a positive indicator
increase both physical activity [10] and motivation for physical about the ability of the Precious app to evoke positive cognitions
activity [21], and the gamified visualizations may also appeal about physical activity. The Precious app, however, has limited
to users who would not find self-regulation techniques means for exploring possible negative elements related to
interesting as such. increased physical activity or positive aspects of maintaining
inactivity, which are often identified in face-to-face counseling
Feasibility Testing [32]. One option for addressing sustain talk would be offering
The feasibility analysis of participants’ engagement with the a problem-solving tool with strategies to overcome hurdles, as
Precious app addressed the following questions: (1) How did done by Friederichs et al [73,74].
participants discuss autonomy support? and (2) what kind of
change talk did the Precious app elicit in the users? Surprisingly, the Time machine tool for using mental rehearsal
of past and future behavior did not elicit change talk during use.
Research Question 1: How did participants discuss As the tool was tested by only two users, it is too early to
autonomy support? conclude that this tool would not support other participants. On
In line with the self-determination theory, participants valued the basis of a fast pace with which participants advanced through
the autonomy supportive features, such as the tailoring of goals, all the Precious app features, more structured guidance (selecting
behaviors, and activities, instead of an externally set behavioral options, typing answers, or listening to instructions) may work
target, as seen in previous Web-based interventions [92,96]. better on a smartphone platform than a list of open questions
The amount of choice was generally perceived positively, and imagination tasks.
although a couple of participants questioned the high number Analyses of the think-aloud walk-throughs underlined how
of options. Some also expressed concerns that their selections making selections while using the app is part of the discourse
might limit their future options. To answer these concerns, we on change or a form of implicit change talk. The CLEAR coding
added tutorials emphasizing that all the app functionalities will system, used for recognizing change talk [94], suggests that
stay available despite the personalized suggestions and that the when participants select numbers with tools such as the
suggestions are based on their selections only, which can be Importance and Confidence rulers, change talk should only be
changed at any time. coded if the participant provides a verbal qualifier for the
As the Precious app was designed around a list of preselected number. At the first stages of analysis, we aimed to extend this
answer options, it could not offer a complete freedom of choice principle to all the interactions with the Precious app, analyzing
to the users. A digital service needs to find a balance of the only clear oral statements. Soon, we discovered that participants’
freedom given to the user and the amount of content that can selections were so embedded in the discourse that including
be tailored to users’ wishes. The more determined the answer interactions with the service was indispensable to get an accurate
options are, the more tailored suggestions can be offered to picture of the participants’ thought processes.
those specific choices. The more freedom the user has in The implicit change talk (ie, making selections that indicate
indicating their preferences, the higher is the risk that the app exercise intentions) may differ from change talk that is elicited
content will not meet those wishes. It is also not known how verbally in interactions with a coach or counselor. Miller and
accurately users want their ideas to be mirrored. Simply Rollnick [32] point out the difference of reactions when just
rephrasing users’ preferences may not be optimally engaging: thinking about questions silently, writing down the answers, or
One study found an app more engaging when it included saying them to someone else. Although interacting with an app
recommendations for people resembling the user, instead of might not fully correspond to a face-to-face counseling, our
recommendations based on personal history only [97]. One results indicate that users can be encouraged to actively reflect
option would be an open platform that the users could use to options with a digital service. However, it should be noted that
create content for their own needs, creating their own goals, the think-aloud walkthrough procedures were undertaken in the
self-regulation techniques, and feedback systems. This type of presence of a researcher, which might have affected participants’
tool would focus on offering information on possibilities and reactions.
rationales of using specific techniques, as is done in the What’s
next? tool of the Precious app. Offering a service with relational elements and tailored feedback
may exceed the impact of simply writing down an answer, but
it is possible that the relatedness experienced with the service
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moderates this effect so that the more strongly the user feels an The current implementation of the app is mostly text based.
app is an active, responsive body in the interaction, the stronger Several elements of gamification could be taken further, for
the impact of the intervention is. The more autonomous and instance, the Time machine tool offers a rich platform for visual
interactive digital services become, the more users may feel elements that would enhance the user experience [80]. However,
responsible for and committed to the actions negotiated with adding complex graphics does not automatically increase user
them. Getting users to select answers on their personal choices, engagement, and text-based elements have been found as
values, and achievements may also increase their engagement effective in increasing physical activity as a digital avatar [99].
with the app via activating users’ representations of their identity In addition, the level of service customization is currently tied
and self-image. In gaming research, players have experienced to the user’s time and patience to fill in self-evaluations.
digital games to be most intrinsically motivating when their Evolving technologies offer increasing opportunities to
gaming experiences have been congruent with their ideal selves automatically detect and tailor to user emotions [100],
[98]. depression [101], stress [102], and even sarcasm [103]. Within
the Precious app project, the use of social media posts for mood
Limitations detection was examined but was not included in the current
The think-aloud interviews only assessed a brief (30-60 min) version [104]. These techniques offer promise, but more
use of the Precious app features. Participants did not have the evidence is needed, whether gamified or chatbot-type interactive
chance to see how their physical activity accumulates over time content engages users more in the behavior change process than
or how the app’s feedback messages depend on their goal text-based solutions.
progress. Thus, the interview only provided information on
participants’ initial reactions to the app’s motivational and Conclusions
self-regulatory features. For this reason, despite studying This paper described the development and feasibility testing of
perceived autonomy support, the interviews did not address the the Precious app. We suggested that an app can support
two other basic needs of the self-determination theory (ie, engagement in the behavior change process through two
competence and relatedness), as we hypothesized these to pathways: encouraging active reflection of users’ motivations,
increase through regular use of the app, with the rules engine capabilities, and opportunities for physical activity and providing
providing encouragement and feedback on behavior. Similarly, gamified elements with challenges and fun. Both pathways can
the gamified elements can only be studied after extended use satisfy users’ psychological needs of autonomy, competence,
in the natural environment. and relatedness, increase their autonomous motivation, and
support their self-regulation.
The features of the Precious app were still being developed
through the feasibility interview phase, meaning that some The novelty of the Precious app is in providing relational support
features were available for the last interviewees only. What’s and addressing both reflective and spontaneous ways of
next?, Time machine, and Confidence ruler were tested by only motivating users. The Precious app aims to support an active
two participants because of late implementation. As is typical cognitive engagement with the behavior change process using
for pilot studies [27], the sample size is a potential limitation reflection tasks. The app builds relatedness with relational
for generalizing the results to a wider population. Future studies techniques from motivational interviewing and by supporting
could use larger samples of individuals of a certain age, activity basic psychological needs described in the self-determination
level, or technology literacy to provide a broader representation theory. Gamification elements include the self-regulation tool,
of different types of users. which helps users to set goals, make plans, and monitor their
progress with a mountain visualization. To collect and present
Future Directions physical activity data accurately, the app aggregates data from
Interaction with technology needs further focus on the several sources: activity bracelets, smartphone sensors, and
behavioral sciences. Despite the relational nature of motivational self-reports. The app consists of independent tools that can be
interviewing, studies offering digital motivational interviewing switched on and off, enabling tailoring of personalized
features rarely discuss how accurately it can be delivered with suggestions and testing specific intervention elements in a
technology and how complexities related to digitalization of controlled way.
motivational interviewing might be addressed [37]. Current
definitions of BCTs primarily relate to interactions between The feasibility interviews of the digitalized motivational
humans [8]. In future work, we need to define if digital services interviewing features revealed that participants value
can be considered active participants in interactions. For personalization options, but the app also needs to clearly
instance, considering the technique Review behavior goal(s) communicate how the information collected from users will be
jointly with the person [8], is the reviewing done jointly if it is used for recommendations and tailoring and which choices users
suggested by a digital tool or a chatbot and is a digital service are able to change later. During the think-aloud interviews,
with relational elements able to provide Social rewards? [8]. motivational app features elicited change talk on needs, reasons,
These questions need addressing when artificial intelligence and desires to change, whereas self-regulatory features elicited
becomes increasingly widespread: at what point does an commitment and taking steps toward change types of change
interactive, chatbot-type service start to be a companion in talk. This active engagement in self-reflection can be perceived
decision making? as a proxy for engagement in the first steps of the behavior
change process. The fast pace with which users typically
advanced through the app suggests that smartphone-based
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interventions may benefit from interactive functions instead of suggest that this can be done by addressing users’ psychological
open questions and imagination tasks. needs and by supporting active self-reflection. The impact of
specific intervention elements on individuals’ self-regulation
Apps supporting behavior change need to engage users in the
and daily physical activity over time will be tested in a series
behavior change process. Feasibility tests with the Precious app
of N-of-1 field studies [105].
Acknowledgments
We thank the other members of the PRECIOUS consortium for their contributions to the project, Dr Felix Naughton and Professor
Stephen Sutton for their valuable advice, and Mirte Reimerink for the help with the interviews. We want to sincerely thank the
anonymous reviewers whose comments helped to improve the paper. This research has received funding from the European
Community's Seventh Framework Programme for the PRECIOUS project (grant agreement number 611366), from the European
Union project, RICHFIELDS (grant agreement 654280), from the KAUTE foundation grant to support ambitious research work
in a high-quality foreign university or research institution to JN, from Yrjö Jahnsson foundation to JN, and from the Netherlands
Organisation for Scientific Research (Rubicon award to KK; grant number 446-14-004).
Conflicts of Interest
None declared.
Multimedia Appendix 1
‘How to get there?’ tool for linking users’ favorite activities and outcome goal.
[PNG File , 72 KB-Multimedia Appendix 1]
Multimedia Appendix 2
Journey view, map of gamified achievements.
[PNG File , 194 KB-Multimedia Appendix 2]
Multimedia Appendix 3
Table on participants’ characteristics.
[DOCX File , 14 KB-Multimedia Appendix 3]
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Abbreviations
API:  application programming interface
BCT:  behavior change technique
CLEAR:  Client Language EAsy Rating
MET:  metabolic equivalent
PRECIOUS:  PREventive Care Infrastructure based On Ubiquitous Sensing
RQ:  research question
Edited by G Eysenbach; submitted 24.11.18; peer-reviewed by J Inauen, R Rogers, D Baretta; comments to author 31.03.19; revised
version received 26.09.19; accepted 22.10.19; published 30.01.20
Please cite as:
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
Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and
Feasibility Testing of the Precious App
JMIR Mhealth Uhealth 2020;8(1):e12884
URL: https://mhealth.jmir.org/2020/1/e12884
doi: 10.2196/12884
PMID:
©Johanna Nurmi, Keegan Knittle, Todor Ginchev, Fida Khattak, Christopher Helf, Patrick Zwickl, Carmina Castellano-Tejedor,
Pilar Lusilla-Palacios, Jose Costa-Requena, Niklas Ravaja, Ari Haukkala. Originally published in JMIR mHealth and uHealth
(http://mhealth.jmir.org), 30.01.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic
information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must
be included.
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