Smartphone application for adolescents with anorexia nervosa: an initial acceptability and user experience evaluation

Anorexia nervosa (AN) has one of the highest premature mortality rates among psychiatric disorders [1‐3]. It may lead to multiple psychiatric and somatic complications [4] and have a significant impact on quality of life [5]. Despite the severity of this disorder and while many studies have highlighted the importance of early diagnosis and interventions to improve recovery prospects [6, 7], there are many barriers that may delay AN’s diagnosis and treatments. These barriers include the lack of training and resources of primary care professionals about eating disorders (EDs) or limited access to EDs services because of geographical barriers, long waiting lists and rigid admission rules [8, 9]. Moreover, the impact of COVID-19 has exacerbated these problems of access to care. Indeed, pandemic-related restrictions induced many disruptions in usual care conditions, such as face-to-face therapies, combined with an increase in EDs-related demands for care [10‐12].

In this context, the widespread distribution of smartphones, and thus the day-to-day interventions and assessment opportunities they provide through applications, makes them relevant devices in improving patients’ care [13]. Digital interventions have proven their effectiveness in treating psychiatric disorders [14‐16] and several studies have shown the effectiveness of online E-Health ED programs in decreasing ED behaviors, attitudes and beliefs [17]. Their effects appear to be based on enhancing motivation to change [18, 19] and increasing patients’ commitment within therapy [20]. Furthermore, these interventions seem to be cost-effective ways of increasing the accessibility and availability of mental health care services for individuals with ED symptoms [21, 22].

Even though online E-Health ED programs become more common, recent reviews showed that smartphone applications targeting ED, especially AN, are still rare and poorly evaluated [17, 23‐25]. They also highlighted that existing applications failed to incorporate all smartphone capabilities that could deliver an entirely personalized intervention. Aiming to determine which components of web-based self-help interventions are associated with ED symptoms improvement, Barakat et al. [17] found that using different media channels is a beneficial feature of the interventions, while automated feedbacks (i.e., reminder, personalized message, summary of self-monitoring input data, etc.) appear to be associated with less improvement. Conversely, some authors showed that personalized feedbacks are prone to enhance digital interventions’ effectiveness [26, 27]. Smartphones apps allow a more flexible and personalized use of feedbacks, rendering this type of digital intervention efficient and easy to commit to. These are important features to consider while developing E-health programs to guarantee the best user experience possible. Digitally copying content from a manual is not enough to create engaging interventions, and E-health programs often have a high drop-out rate [15‐17, 22, 28, 29], especially among children and adolescents [30], which undermines their effectiveness. Taking into account that there is an ever-growing number of apps available on the market, adopting a new one and using it over time becomes a challenge. One out of four mobile apps is never used once installed and 26% of all apps are discarded after a single use [31, 32]. Factors contributing to the adoption of an e-health intervention also need to be taken into account from the development’s very beginning [30] and user experience seems to play a major part in whether a product is adopted or not [33]. A product’s adoption, being the first step in users’ commitment to it, is necessary if we hope to spread its use on a larger scale, which is one of the great benefits of using new technologies.

To build a functional product, an app’s creation process requires several important steps before programming. The first stage is the identification and definition of the theoretical frame [34]. This step aims to precisely build the app’s functionalities, based on a sturdy theoretical model, and relying on empirical data, which is essential to create an efficient final product [27, 35]. In the second step, evaluating user experience during a short period of time, simulating the app’s first use, allows to modify the program before developing it further based on users’ expectations, to facilitate its adoption in real-life conditions [15, 36, 37]. Qualitative evaluation is a relevant tool in user-centred design allowing to better approach users’ experience [34, 38].

By following these two steps, we first developed an AN companionship app prototype for teenagers. Then, we conducted a questionnaire and qualitative study in a group of expert practitioners and a group of patients suffering from AN, aiming to evaluate the app’s early acceptability as well as users’ needs and experience.

This study focused on an essential step in app development by evaluating its early acceptability and user experience in its initial phase. In general, the app’s overall attractiveness was adequate, but the UEQ results showed weaker dimensions in user experience, including novelty, dependability, and efficiency, which matched some participants’ comments. Efficiency score was low on the UEQ, which participants confirmed by expressing mixed beliefs. Qualitative data showed that when participants thought the app was effective, it promoted its adoption, whereas it hindered it when they thought it was ineffective, which is consistent with current literature [28, 30]. Moreover, several models about apps adoption highlight that the perceived efficiency of a product is one of the key elements guiding the intent to use, which is essential in deciding whether or not to adopt a product [32, 33]. Participants’ expectations included that the app needed to be properly broadcasted (online and on different apps stores), and recommended by health workers. Indeed, Kim et al. [33] in their multi-stage adoption model state that social influence (i.e., how strongly an individual believes that important others think he or she should use the technology), which is also a key element in the intent to use, could influence positively the perceived efficiency. Spreading the app’s use could thus improve its credibility and expected efficiency [28]. Besides, it seems that being recommended by a health worker is the best way to boost an app’s adoption [63]. Concerning novelty, patients did not find the aesthetic very modern or appealing, which hindered the installation of the app. Clinicians, in contrast, were satisfied with the aesthetic. The low dependability score could be related to difficulties experienced by clinicians when navigating in the app, as well as patients’ opinions about design that fell short of their expectations. The app’s aesthetics and design are also key elements in its adoption process, still according to some comprehensive models of apps adoption. Indeed, on one hand, they take part in the user experience which contributes to the satisfaction during use, turning the intent to use into adoption [31‐34]. On the other hand, aesthetics and design also seem to guide users as early as the app’s search or exploration, through screenshots displayed on stores, influencing the decision to install the app [31]. The study’s qualitative data shows the different expectations, towards these two dimensions, between adolescent users and adult clinicians. This highlights the importance of including users in the app development process as early as possible to better understand their needs and preferences [29, 38, 55]. This is particularly true for adolescents, who have always known these tools and use them daily. They will express different, often higher, expectations than adults, specifically about customization features [15, 30].

The qualitative data revealed many expectations for this application. Patients and clinicians agreed on the importance of the psychoeducation feature. Patients highlighted the difficulties they faced when they looked for information about the disorder, such as too much information, guilt-inducing information or even false information that could reinforce false beliefs or symptoms. These experiences are consistent with the Arts et al. Study that showed that AN online information was often of variable quality and difficult to read [64]. Even more, and especially for adolescents, not understanding the disorder and the need for treatment is a real obstacle in implementing appropriate treatment [9]. It was therefore expected that having a single source of reliable data on the disorder or on dietary facts would limit this risk and facilitate communication with caregivers. Patients also expected to be able to choose items about self-esteem and social skills, so the app would be relevant during disorder’s later stages. The user’s ability to choose elements that represent situations with which they identify seems, according to other studies [29, 30, 34, 55], to be a personalization feature that improves engagement and adherence.

Participants have also brought forward that there are internal factors, specific to the disorder, that could hinder the app’s adoption. Patients thus highlighted that shame and denial could be limiting factors. Feelings of shame were comprised of two dimensions. On one hand, they said that exposing oneself on account of owning an app dedicated to ED could be embarrassing through the eyes of others, for example because of untimely notifications, or the phone being looked “over” the shoulder. On the other hand, shame could be induced by reminding patients of their disorders, of the difficulties they face, reinforcing the distorted way they see themselves, which is an essential part of the disorder. Social influence, as was discussed earlier, is a major parameter in building the intent to use [32, 33]. It can therefore be influenced negatively by shame and disorder-related stigmas, which are well-known barriers to the search for help and treatment in EDs [8, 9], and more generally in mental health care. We can thus see how important it would be that the app felt safe and “without judgement”. Beyond these considerations, the app’s design allowing it to not being instantly labelled as a mental health app dedicated to EDs could improve the sense of security and intimacy patients are looking for and avoid self-stigmatization reinforcement. Choosing carefully the app’s title could also be important. For example, Huang et al. [65] who studied apps aiming to alleviate anxiety found that apps with a title referring directly to anxiety disorders or symptoms had a lower installation rate than those of which the title was not symptoms-related.

Gamification features were well accepted and could even be perceived as motivating and enjoyable. However, some participants expressed worries about some elements that could bring about obsessions or pressure. This underscores the importance of carefully choosing gamification mechanisms and how they are implemented to better meet patients’ needs and symptoms, avoiding adverse effects [52, 53, 66]. However, when properly implemented, these features can be great assets, still underused, in improving interventions’ efficiency and commitment to [13, 54, 55].

There were different points of view between clinicians and patients about the app’s use. Clinicians envisioned a short-term use, mainly in searching for help surrounding the disorder. They mostly expected the app to help screen patients and direct them towards proper care. Besides, it seems like short-term interventions are usually more efficient, maybe because apps tend to be less used over time [13]. Finally, some clinicians did not think this app would be useful in a “face-to-face” setting, or thought it could increase patients’ expectations, thus creating the risk of disappointment. Lindgreen et al. [67] showed that using this type of tool during consultations could also create distress for clinicians and lower their work satisfaction. Indeed, in this study, clinicians felt like they might not have the necessary technological skills, or that there could be a gap between patients’ expectations and theirs, thus potentially damaging the therapeutic relationship or alliance and diminishing patients’ trust in their clinicians. This shows how important it is to think about objectives and use recommendations for patients but also for clinicians, to avoid adding a burden to their practice. Patients seemed to expect a strong sense of intimacy with the app. Most imagined using it occasionally, if necessary, but expected a follow-up throughout the disorder’s evolution. They could thus come look for information or personal motivations (i.e., life projects, personal values) depending on their needs at that precise moment. Patients expressed needing more than text coping strategies, such as links to different media via the app. This concurs with Barakat’s et al. [17] results, stating that using several media types was associated with a better ED symptoms improvement. Furthermore, it seems that, during the pandemic, difficulties in regulating one’s emotions that ED patients face could have played a major part in ED symptoms aggravation in that period [10]. COVID-19’s impact on health care systems also shows the importance of developing new methods in helping ED patients when health care becomes less accessible [10, 11]. Finding efficient ways to distribute these coping strategies, thanks to the different medias they can provide, seems to be an e-health interventions’ relevant challenge.

This study’s main limitation was the selection bias: only hospitalized patients were recruited. This limits the results’ generalization to different stages of the disorder but, nonetheless, offers information about users’ needs at the start of the disorder and in already coordinated care. A second limitation was the small number of participants, so these results cannot be considered definitive or stable because we did not reach data saturation. However, we did not aim to be exhaustive, but rather to get an overview of important topics to address when developing an app, keeping in mind the flexibility a fast implementation needs. Many studies have insisted on the importance of using alternative methods in e-health intervention evaluation [15, 36, 38, 55]. Indeed, traditional evaluation methods, such as randomized controlled trials, are not compatible with development process, because of their long implementation timeline and the fast-evolving users’ expectations and technological progresses. Rapid and iterative testing methods with results implementation involving users in their development allow this flexibility. Tools used during this study are an example of these kinds of tests. More than allowing to punctually evaluate the app, they can assist in building a reference to better monitor different versions’ evolution and improvement features that must be implemented over time [36]. Traditional methods are still relevant in evaluating sparse data, like efficiency, once this process is over [15].

Developing new technologies in AN accompaniment could enable to bypass some of the barriers they face when trying to access specific care. These solutions are not however usually very engaging for users, particularly in adolescent population which have different expectations than adults. This study shows the importance of including users in the different stages of an e-health intervention development. It identifies needs, general patterns of use and adherence, which may be very different from those envisioned by clinicians. Patients’ expectations were mainly centered around getting reliable information as well as an emotional and motivational accompaniment. Clinicians mostly expected the app to help health workers screen and evaluate patients, rather than for follow-up. Several barriers to the app’s adoption were outlined, especially by the patients, such as design and aesthetics, or doubt in these tools’ efficiency. However, suggestions for improving the adoption of the application were made, like internet broadcasting and professional recommendation, and making the app design non-stigmatizing. These findings could help to make the right changes in order to meet users’ needs, which could significantly improve the program’s adoption and adherence, and thus its effectiveness. Developing a mobile app is a continuous process that should regularly include these evaluations, until its efficiency is properly evaluated.