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

Oscar Castro, Jacqueline Louise Mair, Alicia Salamanca-Sanabria, Aishah Alattas, Roman Keller, Shenglin Zheng, Ahmad Jabir, Xiaowen Lin, Bea Franziska Frese, Chang Siang Lim, Prabhakaran Santhanam, Rob M van Dam, Josip Car, Jimmy Lee, E Shyong Tai, Elgar Fleisch, Florian von Wangenheim, Lorainne Tudor Car, Falk Müller-Riemenschneider, Tobias Kowatsch, Oscar Castro, Jacqueline Louise Mair, Alicia Salamanca-Sanabria, Aishah Alattas, Roman Keller, Shenglin Zheng, Ahmad Jabir, Xiaowen Lin, Bea Franziska Frese, Chang Siang Lim, Prabhakaran Santhanam, Rob M van Dam, Josip Car, Jimmy Lee, E Shyong Tai, Elgar Fleisch, Florian von Wangenheim, Lorainne Tudor Car, Falk Müller-Riemenschneider, Tobias Kowatsch

Abstract

Background: Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and methods: A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results: Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions: The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Keywords: behaviour change; chatbot; cognitive behavioural therapy; depression; diabetes; health programme; mHealth.

Conflict of interest statement

FvW, TK, and EF are affiliated with the Center for Digital Health Interventions, a joint initiative of the Department of Management, Technology, and Economics at ETH Zurich and the Institute of Technology Management at the University of St Gallen, which is funded in part by CSS, a Swiss health insurer. TK and EF are also the founders of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, Pathmate Technologies was not involved in any way in the design, interpretation, and analysis during the study, or in writing the paper. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

© 2023 Castro, Mair, Salamanca-Sanabria, Alattas, Keller, Zheng, Jabir, Lin, Frese, Lim, Santhanam, van Dam, Car, Lee, Tai, Fleisch, von Wangenheim, Tudor Car, Müller-Riemenschneider and Kowatsch.

Figures

Figure 1
Figure 1
Conceptual model of LvL UP. Black boxes are intervention components. White boxes are intervention outcomes. Conversational Agent (CA), Non-communicable diseases (NCDs), common mental disorders (CMDs). ‘[No.]' refers to the behaviour change technique labels (93): 1.1. Goal setting (behaviour), 1.2. Problem solving, 1.3. Goal setting (outcome), 1.4. Action planning, 1.5. Review behaviour goal(s), 1.7. Review outcome goal(s), 2.2. Feedback on behaviour, 2.6. Biofeedback, 3.1. Social support (unspecified), 3.3. Social support (emotional), 4.1. Instruction on how to perform the behaviour, 5.1. Information about health consequences, 5.3. Information about social and environmental consequences, 5.6. Information about emotional consequences, 6.1. Demonstration of the behaviour, 6.2. Social comparison, 6.3. Information about others’ approval, 7.1. Prompts/cues, 8.1. Behavioural practice/rehearsal, 8.3. Habit formation, 8.7. Graded tasks, 9.1. Credible source, 9.2. Pros and cons, 9.3. Comparative imagining of future outcomes, 10.3. Non-specific reward, 10.6. Non-specific incentive, 11.2. Reduce negative emotions, 12.1. Restructuring the physical environment, 12.2. Restructuring the social environment, 12.3. Avoidance/reducing exposure to cues for the behaviour, 12.6. Body changes, 13.2. Framing/reframing, 14.4. Reward approximation, 15.1. Verbal persuasion about capability, 15.3. Focus on past success, 16.2. Imaginary reward, 16.3. Vicarious consequences.

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