Health apps – a help or a hindrance?
There are many free apps available that claim to support health, from getting fit and losing weight, to quitting smoking and improving mental health. The NHS even has its own web page for NHS-approved apps.
But is there any evidence that health-related apps have any impact? What kind of apps are available and how can we make educated choices about which ones we use?
Can apps help us change our behaviour and follow a healthier lifestyle?
Used in the right way, by the right person, research suggests that health apps can help encourage behaviour change, with the potential to help you:
- Lose weight – as seen in a UK study of 128 overweight volunteers published in 2013. Participants using the smartphone app (My Meal Mate) lost more weight than those using a website or paper diary, and stuck to the trial for longer.
- Reduce alcohol consumption – according to a study of 119,713 people using an app produced by Drinkaware, designed to help monitor and reduce their alcohol consumption. The study concluded that the app is a useful tool for raising awareness about drinking and potentially reducing consumption, but primarily in individuals already committed to making such changes.
- Improve mental health – according to a 2018 Japanese study with 81 participants. The study showed that cognitive behavioural therapy (CBT) delivered via a smartphone app was effective in alleviating moderate or severe depression in people who were unresponsive to antidepressant medication.
- Quit smoking – as indicated in a study of 102 young adult smokers. The study, which compared an app vs. a text messaging service, suggested the app helped smokers to quit but not as quickly as a text messaging service.
- Increase physical activity – a systematic review of published research in 2015 concluded there was modest evidence that a number of apps to improve diet, physical activity and sedentary behaviour show promise for prompting both children and adults to change their behaviour. The existing evidence base is largest for proving the effectiveness of apps to increase physical activity in adults.
So, is an app the answer?
Not necessarily. Many of the studies above are small-scale and short term, so they aren’t as reliable as larger, long-term studies.
Plus, the very nature of health apps means they rely on consistent user engagement. Sample sizes can end up smaller than intended or reduce in size over the course of a study if participants drop off, making long-term benefits harder to prove. For example, in the study of the Drinkaware app mentioned earlier, the number of people using the app dropped to barely 15% after 4 weeks.
Can health apps really change our behaviour?
An evidence review published in 2016 analysed 23 pre-existing studies on a range of different health apps used in high-income countries. It found that 17 of them reported statistically significant measures of successful behaviour change in the area they were targeting. The studies suggested that some features improve the effectiveness of apps, such as less time consumption, user-friendly design, real-time feedback, individualized elements, detailed information, and health professional involvement.
The majority of successful studies tend to indicate that health apps used for behaviour change are most effective when used by people who are already committed to the end goal – whether that’s quitting smoking or losing weight.
Nonetheless, their effectiveness cannot be guaranteed for everyone. In fact, some studies have demonstrated that even well-known apps can be unsuccessful in prompting significant behaviour change. For example, an American study published in 2014 found that the free MyFitnessPal app was not effective in helping overweight patients lose weight in a clinical setting over a 6-month period. And, while most users reported high satisfaction with MyFitnessPal logins dropped sharply after the first month.
How do health apps work?
Since a large number of health apps are designed to encourage behaviour change, many of them employ one or more well-known, scientific behaviour change techniques.
These include planned behaviour or social cognitive theory, and behaviour change techniques such as self-monitoring, feedback on performance, and tailored messages. Mental health apps or apps designed to remedy alcohol addiction are more likely to use specific behavioural therapies, such as CBT.
- Gamification is a common behaviour change technique, but it’s possible some app developers are missing a trick. Research published in the British Medical Journal identified that just 4 per cent of the NHS approved Health Apps Library and all top-rated medical, health, wellness and fitness apps, used gamification techniques - such as rewards, challenges and competitions - to encourage behaviour change.
- User engagement is also important when it comes to achieving measurable behaviour change, so the features of an app’s design are integral to its success. Focus groups conducted with staff and students at the University of Southampton identified that security, accuracy and minimal effort required were important factors in using apps to support a healthy lifestyle, whilst tracking behaviour and goals, and accessing information on the go, were also deemed important. To increase user engagement with health behaviour change apps, more information is also needed about which app features and behaviour change techniques people value and engage with the most.
What are the risks?
Very few health apps have had been formally tested for their effectiveness, leading to questions around their stated benefits and concerns around the risk of potential harm.
Within the realms of mental health, for example, users may already be in a vulnerable position before engaging with a mental health app designed to improve their condition.
Researchers at the University of Liverpool have found that whilst a number of mental health apps have been proven an effective method of treatment, many lack scientific credibility and an underlying evidence base, leading to limited clinical effectiveness. Issues can also arise from over-reliance and anxiety resulting from self-diagnosis.
Most startling is the ratio of health-related apps available to download compared to those that are scientifically credible, peer-reviewed and evidence-based. The University of Liverpool research showed that in 2013, there were only 32 published articles regarding depression apps, compared with a total of 1,536 available for download.
It is also possible that any kind of health-related behaviour change app could have the opposite effect to the one intended. A Swedish study published in 2014 tested the effectiveness of two smartphone apps in reducing risky alcohol intake among Swedish university students at social occasions. Male users of one of the apps tested actually increased the frequency of their drinking, with researchers speculating whether the real-time use of a smartphone app might trigger men to compete with others as part of a drinking game.
How can I choose an app that will work for me?
Given that the success of many health apps depends on user engagement and a pre-existing desire for positive change, the best approach is to read reviews from other users, and then test a number of health apps for yourself.
If you engage with your chosen health app frequently, and as it has been designed to be used, over time you should be able to identify whether it is having a positive outcome.
- Health apps seem to be most effective for people who are already committed to making changes to their lifestyle; who use their app regularly; and who use apps alongside other interventions, such as counselling or motivational emails.
- Many people have busy lifestyles, so apps that offer behaviour change support on-the-go are likely to be helpful here.
- More research is needed to identify which specific apps and behaviour change techniques are most effective for improving health in each area and to identify the optimal amount of contact time required.
- Given the number of apps available to download, there is a need for a more robust system for categorising which apps are evidence based, to help people make informed choices.
Naomi Adams, February 2018