Apps to improve diet, physical activity and sedentary behaviour in children and adolescents: a review of quality, features and behaviour change techniques

Schoeppe et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:83 DOI 10.1186/s12966-017-0538-3 RESEARCH Open Access Apps to improve diet, physical activity and sedentary behaviour in children and adolescents: a review of quality, features and behaviour change techniques Stephanie Schoeppe1* , Stephanie Alley1, Amanda L. Rebar1, Melanie Hayman1, Nicola A. Bray1, Wendy Van Lippevelde2, Jens-Peter Gnam3, Philip Bachert3, Artur Direito4 and Corneel Vandelanotte1 Abstract Background: The number of commercial apps to improve health behaviours in children is growing rapidly. While this provides opportunities for promoting health, the content and quality of apps targeting children and adolescents is largely unexplored. This review systematically evaluated the content and quality of apps to improve diet, physical activity and sedentary behaviour in children and adolescents, and examined relationships of app quality ratings with number of app features and behaviour change techniques (BCTs) used. Methods: Systematic literature searches were conducted in iTunes and Google Play stores between May– November 2016. Apps were included if they targeted children or adolescents, focused on improving diet, physical activity and/or sedentary behaviour, had a user rating of at least 4+ based on at least 20 ratings, and were available in English. App inclusion, downloading and user-testing for quality assessment and content analysis were conducted independently by two reviewers. Spearman correlations were used to examine relationships between app quality, and number of technical app features and BCTs included. Results: Twenty-five apps were included targeting diet (n = 12), physical activity (n = 18) and sedentary behaviour (n = 7). On a 5-point Mobile App Rating Scale (MARS), overall app quality was moderate (total MARS score: 3.6). Functionality was the highest scoring domain (mean: 4.1, SD: 0.6), followed by aesthetics (mean: 3.8, SD: 0.8), and lower scoring for engagement (mean: 3.6, SD: 0.7) and information quality (mean: 2.8, SD: 0.8). On average, 6 BCTs were identified per app (range: 1–14); the most frequently used BCTs were providing ‘instructions’ (n = 19), ‘general encouragement’ (n = 18), ‘contingent rewards’ (n = 17), and ‘feedback on performance’ (n = 13). App quality ratings correlated positively with numbers of technical app features (rho = 0.42, p < 0.05) and BCTs included (rho = 0.54, p < 0.01). Conclusions: Popular commercial apps to improve diet, physical activity and sedentary behaviour in children and adolescents had moderate quality overall, scored higher in terms of functionality. Most apps incorporated some BCTs and higher quality apps included more app features and BCTs. Future app development should identify factors that promote users’ app engagement, be tailored to specific population groups, and be informed by health behaviour theories. Keywords: Mobile health (mHealth), Smartphone, Applications, MARS, Behaviour change techniques, Diet, Physical activity, Sedentary behavior, Children, Adolescents * Correspondence: 1 School of Health, Medical and Applied Sciences, Physical Activity Research Group, Central Queensland University, Bruce Highway, Rockhampton, QLD 4702, Australia Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Schoeppe et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:83 Background Unhealthy diet, physical inactivity and sedentary behaviour are highly prevalent health risk factors in children and adolescents [1]. These health behaviours are known to track from childhood into adulthood [2, 3], and contribute to high rates of childhood overweight/obesity, and an increased prevalence of type 2 diabetes and metabolic syndrome in adolescence [4]. Given the scale of the problem – worldwide over 41 million children under 5 years of age are already overweight or obese [5] – population-based interventions that can reach large numbers of children and adolescents easily and at low cost are needed. Smartphone applications are widely used (there are over 2.1 billion smartphone users worldwide) [6] and can reach large numbers of children in real life situations where they live, learn and play. Smartphones and tablets, including the software applications (apps) that run on these devices, have become an integral part of children and adolescents’ lives with large increases in usage rates since their introduction in 2007 [6, 7]. For example, 73% of American, 74% of European and 80% of Australian adolescents regularly use a smartphone [8–10]. With the growth in mobile technologies came the development and popularity of numerous health and fitness apps that can provide behavioural interventions in large population groups [11]. Given the proliferation of apps, it is worthwhile to investigate their potential for promoting healthy lifestyle behaviours in children and adolescents. The appeal of commercial apps to provide health information ‘on the go’ has motivated researchers to utilise commercial apps for behavioural interventions that incorporate proven health behaviour changes techniques (BCTs) such self-monitoring, real-time feedback, social support, and rewards [12]. Despite the potential of apps for pediatric health behaviour change interventions, the behaviour change content and quality of apps specifically targeted to children and adolescents is largely unexplored. Several systematic reviews [11, 13–18] have examined the content of apps to promote healthy lifestyle behaviours in adults or the general population, and their results showed that most apps included self-monitoring, goal-setting, instructions on how to perform a health behaviour and feedback on performance. Only one systematic review [17] has evaluated the content of commercial health and fitness apps targeted to children and adolescents, and its findings showed that apps incorporated gamification elements and goal-setting but lacked concrete expert recommendations about healthy lifestyle behaviours. However, this review [17] focused on weight loss and addressed diet and physical activity, but not sedentary behaviours. In fact, many previous reviews of apps targeting adults [11, 14, 15, 19] have mainly focused on apps to promote physical activity. As such, little is known about the potential of using apps to Pa (...truncated)