The Doctor Will “Friend” You Now: A Qualitative Study on Adolescents’ Preferences for Weight Management App Features

Abstract

Objectives:

Primary care providers report a lack of resources as a barrier to managing adolescent obesity. Mobile health applications (apps) may be helpful in weight management; however, adolescents’ preferences for weight management app features are unknown. Our objectives were to provide insight into adolescents’ preferred weight management app features and elicit facilitators and barriers to app use.

Methods:

Using the qualitative content analysis method, 14 interviews with adolescents with overweight/obesity were conducted in rural and urban pediatric offices in South Carolina. Eligibility criteria included being 13 to 17 years old, having a body mass index at or above the 85th percentile for age and sex, and having access to a smartphone or tablet. Semistructured key informant interviews were conducted from May to October 2017. Participants were presented with three popular mobile health apps and asked to complete tasks and comment on their various features and usability. Summative content analysis coding was performed on interview transcripts, and interviews were conducted until thematic saturation was reached.

Results:

Seventy-one percent of participants were from a rural practice, 64% were White, and 86% had a body mass index higher than the 95th percentile. Familiarity with similar apps and accessibility of apps on their smartphones promoted app use. The need for wireless Internet, operating difficulties, or privacy concerns were barriers. Nutritional education, physical activity tracking, and social connection were desirable app features.

Conclusions:

Adolescents have expressed preferred app features to help them manage weight; however, further work is needed to see whether these features are effective.

The prevalence of obesity among adolescents 12 to 19 years old in the United States is 20.6%.¹ Obesity in adolescence increases the risk of type 2 diabetes mellitus, hypertension, and dyslipidemia.^2–4 Severe obesity at the age of 18 years was found to increase diabetes mellitus by 42% and hyperlipidemia by 61%.⁵ In addition it has been found that obese children have a threefold higher risk for hypertension than do nonobese children.⁶ As such, it is important to find effective interventions that enable adolescents to better manage their weight and prevent known comorbidities. Treating obesity in adolescence is difficult due to lack of resources, time constraints, and patient adherence.^7–9 Readily available technology, such as smartphone applications (apps), however, may help treat obesity in adolescents by overcoming these barriers because they can offer additional resources/tools, provide increased contact and counseling time, and help patients stay engaged with their weight management plan.¹⁰

Smartphone apps have been used to manage other chronic diseases^11–13 in adolescents, and the use of apps is prevalent among adolescents of all races and socioeconomic status.¹⁴ Although the US Census Bureau in 2017 reported a reduced level of Internet connectivity in households with lower incomes, these households tend to have smartphones instead of laptops/personal computers.¹⁵ Although not ideal, 61% of adolescents who live in a household with <$30,000/year income, have access to a smartphone.¹⁴ The prevalence of smartphone use has increased during the past decade as 85% of Black teens and 71% of White and Hispanic teens report having access to a smartphone.¹⁴ In addition, 58% of teens have downloaded apps to a cellphone or tablet computer.¹⁶ Given the prevalence of smartphone app use and the high level of adolescent engagement with apps, smartphone apps may provide a resource for primary care providers (PCPs) to help adolescents better manage overweight/obesity.

Although the literature shows that mobile apps may be helpful in engaging adolescents and helping adolescents make healthy behavioral changes,^17–21 there is a dearth of information about adolescents’ use of apps for overweight/obesity treatment. Before testing for efficacy, adolescents’ preferences for smartphone app features as well as their current use of weight management apps need further investigation.^22–24 It is critical to identify the app features that adolescents are most likely to use before analyzing the efficacy of app features as interventions in assisting adolescents with weight management.

The objective of this qualitative study was to explore adolescents’ preferences about weight management app features and gain insight into features that will engage adolescents versus features that frustrate and discourage app use. These results could inform which app features may be helpful interventions for adolescent weight management.

Methods

Setting

Participants were recruited from an urban and a rural practice via their participation in the South Carolina Pediatric Practice Research Network.²⁵ The urban practice is a resident clinic staffed by faculty members from the division of general pediatrics at the university medical center and has 12,500 visits per year. The patients in the urban practice are 89% Medicaid recipients, and 84% identify as Black, 11% as White, and 4% as Hispanic. The rural practice is staffed by 3 pediatric primary care providers and has 13,000 visits per year. The patients in the rural practice are 50% Medicaid recipients and 50% identify as White, 35% as Black, and 15% as Hispanic.

Recruitment, Enrollment, and Data Collection Procedures

Patients were eligible if they were between 13 and 17 years old, had a body mass index ≥85th percentile for age and sex on 2000 Centers for Disease Control and Prevention growth curves, and had daily access to a smartphone or tablet. Patients and their families were approached during clinic visits or by telephone. If patients were interested in participating, then study procedures were explained and a date for obtaining informed consents and interviews was scheduled. Informed consent was obtained from parents and assent from patients. Semistructured key informant interviews were conducted from May through October 2017 in an examination room of one of the offices and lasted 30 to 60 minutes. Interviews were audiorecorded and professionally transcribed. We provided compensation for participants’ time with a $20 Amazon gift card. Participants were asked to complete a brief questionnaire regarding demographics.

Interview Guide Development

Using principles of qualitative interviewing,²⁶ the interview guide (see Appendix A, [http://links.lww.com/SMJ/A229]) was designed with expert input with the goal of focusing participative conversation on adolescents’ prior use of popular, commercial weight management apps, their preferred features of these apps, and their frustrations and/or concerns using these apps. After the questions about the prior use of apps, the interview guide included an introduction to three weight management apps that were selected because they are free, provided a variety of different features, and are compatible on both iOS and Android devices. Each app was presented individually, and participants were asked to complete tasks to explore unique features in each app to help them better understand how the apps could be used. Some tasks were as follows: record that you ran for 30 minutes today, take a picture of the barcode on the snack item in front of you and find a healthy alternative to that snack item, customize a 20-minute workout, and read about others’ success stories in getting healthier and better managing their weight. Tasks were determined based on the features the app had to offer.

The order in which the apps were introduced and used were changed with each interview. Questions that followed the orientation to each app included participants’ preferred and nonpreferred features, features that would keep them engaged in developing a healthy lifestyle, and features that would discourage app use. Finally, adolescents were asked to what extent the features could specifically be helpful to them or other adolescents in managing weight. If advertisements popped up in the app, then they were immediately closed.

Data Analysis

Qualitative summative content analysis²⁷ was performed on interview transcripts, and interviews were conducted until thematic saturation was reached. Thematic saturation was determined by the redundancy of ideas presented by participants and the lack of emerging themes, consistent with definitions of thematic saturation as the point at which no new themes emerged from participant observations.²⁸ Transcripts were read and coded by C.B.S.G. and E.D., who then met to discuss their overall impressions of the data and themes that they observed. Then they both reread the interviews to select quotes that highlighted the themes in the interviews and met again to discuss interpretation. Any disagreements in coding were resolved with discussions. They made sure that the data accurately represented what participants had stated, by comparing recordings of interviews with transcriptions and related coding. This study was approved by the institutional review board at the Medical University of South Carolina.

Results

Participants

We achieved thematic saturation after conducting 14 interviews with adolescents, and recruitment was suspended. More than half of the participants were between 15 and 17 years old, and 86% had a body mass index >95th percentile. Most participants were recruited from the rural practice, where there was a higher rate of adolescents and parents responding to recruitment. See Table 1 for participant demographics. This high rural representation contrasts with Federal Communication Commission reports of poorer Internet access and broadband speed in rural than in urban areas.²⁹

Table 1.

Participant demographics (N = 14)

Sex, female (%)

8 (57)

Age range, y (%)

13–15: 6 (43)

15–17: 8 (57)

BMI percentile (%)

85th–<95th: 2 (14)

95th–<99th: 8 (57)

≥99th: 4 (29)

Race (%)

Black: 6 (43)

White: 9 (64)

Ethnicity (%)

Hispanic: 1 (7)

Non-Hispanic: 11 (79)

Unknown: 2 (14)

Participants from type of practice (%)

Rural: 10 (71)

Urban: 4 (29)

BMI, body mass index.

Theme 1: Factors that Promoted the Use of Apps

Familiarity with the apps was the greatest factor for promoting the use of the apps. Participants commonly reported that the apps had a setup similar to other apps they had used previously. Participants believed that this familiarity made the app user-friendly. Almost all of them had used popular apps such as Facebook, Instagram, and Snapchat and specifically reported that they preferred certain weight management apps because it reminded them of those popular apps. In addition, participants reported using smartphone apps in the past if they either received recommendations from others to use the app and/or the app was free or low cost. All of them had used other smartphone apps before the interview, which they had usually learned about from family and friends.

Another factor for promoting app use was ease in use. Participants did not want to spend too long figuring out how to use the app. They wanted an app that was organized and simple to use. Some expressed that if it took too long to figure out how to use the app, then they would stop using it.

Finally, a significant facilitator for the use of apps was that adolescents said they were easily accessible on their telephone/tablet since they always had these devices on them. They were willing to try an app that they could use on their telephone because it would be convenient (see Table 2).

Table 2.

Factors that promoted use of apps

Familiarity

“I think I would like a set up like this. It kind of looks like social media.” “I like it ‘cause it’s kinda like a social media page, but to help you get fit and stuff. And social media’s really big these days….” “Yeah, cause the layout is really easy, in my opinion, to use. And on apps like Instagram and stuff, some kids already have that, so they know like to scroll down and look at stuff and they know how to figure out how to use it easily.”

Ease

“Something very organized and easy to use and it would be fun to use, so they don’t feel like they have to do it, but they want to do it.” “I think I would download it [the app]. It was really easy and organized and you have, if you don’t want to type in stuff, then you can just take a picture of the barcode.” “Everything is colorful. It’s pretty, and it’s really vibrant so you know… it’s very organized.” “This is the most simple layout they have. I like the barcode thing, that’s really cool, and I love the healthy alternatives. I’m thinking of downloading it when I leave.”

Accessibility

“….’cause like, I’m on my phone, I have it with me most of the time. So it’s, like, a good idea, ‘cause it, like, never leaves my side.” “I think since this is all on your phone or iPad, you’re more likely to use it since you always have the device in your hand.” “Well, a lot of people are obsessed with their phones so they’re always on it and can just go on the app and do whatever.”

apps, applications.

Theme 2: Specific Features that Would Keep Participants Motivated and Engaged

Specific preferred features involved nutrition education. This material included nutrient content of foods, nutritional articles, or new recipes. Adolescents in the study liked taking pictures of barcodes on food items with their telephone so that they could identify the nutritional information regarding foods that they were considering eating. In addition, one feature also allowed participants to view healthy alternatives to the food they were considering, which the majority of adolescents reported as helpful.

Participants also preferred apps that recorded physical activity so that they could see how many calories they burned or how many steps they took during the day. Self-monitoring features, such as having reminders, alerts, or notifications to keep them on track with their healthy behavioral goals was a highly preferred feature for these adolescents.

Finally, social connection was a significant theme. Adolescents in the study liked the idea of competing with their friends to see who could exercise more. They had positive comments regarding keeping their family, friends, and even PCPs abreast of their progress in reaching healthy goals. Many adolescents suggested that having their PCP monitor their progress would keep them motivated and hold them accountable to reach their healthy behavior goals. These adolescents agreed that sharing their progress with supportive family, friends, and PCP would help them be successful in reaching their healthy goals.

Participants also spoke highly of the idea of reading on community forums how other adolescents successfully managed their weight. Many shared statements that they would be inspired to hear how others struggled with their weight just like them. They liked the idea of being included in a community and also were willing to share their own progress—both successes and failures—in developing a healthier lifestyle to better manage their weight. Table 3 lists participant feedback on preferred features.

Table 3.

Adolescents’ preferred app features

Feature: Obtain nutritional and physical activity information (tracking calories, taking picture of barcodes of foods, recommendations for new meals or exercise)

“I like how it’s telling you the calories you got in and then like what it’s got in it and stuff. So if it’s got something wrong in there, you can change it.” “Most helpful, it gives you recipes and stuff like that, healthier recipes. It tells me how many calories I burned … And you can go to the community and see what other people are going to better themselves.” “I love just watching it ‘cause it tells me how many steps I do and I like seeing how many steps I do a day and the calories you burn it shows and your heart rate… . I like it.” “Like, the exercises they gave me, some of them I haven’t heard about and it would be fun trying new exercises because you never know how good it can make you feel and the way you work out. It’ll probably get you slimmer in no time!” “It tells you everything. A doctor can only tell you certain stuff and when you go on the app, they’re going to tell you a whole bunch of other stuff, including the stuff the doctor told you.”

Feature: Notifications for exercise and healthy eating (reminders, tips)

“It would be helpful by giving me, like, tips and reminders and showing me notifications to make sure that I make sure I get in my work and my exercise.” “I like the reminder. Like, ‘remember to jog 10 minutes today ‘cause you have soccer practice tomorrow.’ Or, ‘Remember to do some kind of stretch before you go jogging today ‘cause yesterday you hurt your calf muscle.’” “I like how organized it is because I’m OCD real bad. I like to have reminders.”

Feature: Social connection (success stories, showing family, friends, and provider your progress in reaching healthy goals, competing against friends)

“I would feel good about it because it will push me even harder to go above them and to come out victorious.” “… And if you heard success stories, it would help you get motivated to lose weight just like they did.” “Yeah, because it kind of motivates me when people that I know see what I’m doing ‘cause it kind of makes me feel like, if they support me, then I can do it.” “I think I would like that because a lot of people, they get motivated by competition and they wanna win. So, it’ll give you more motivation to get out there.” “Well, for one, you can actually talk to people and get advice from other people that are trying to lose weight like you… .” “I’d do that [sharing progress with family], ‘cause my dad’s trying to lose weight too and all of us are mainly trying to get healthy.” “I would keep logging on to help myself get motivated … And also to share my improvements on my weight loss.” “Yeah, it would be, like, “They do this, and so I should try that because it’s working for them, so maybe it might work for me’.” “It would be a motive to do better ‘cause if your doctor’s watching, then they can see what you’re doing and you want to impress them.”

apps, applications.

Some adolescents also provided suggestions for added features that they believed would enhance the apps. One of the most common suggestions was for apps to offer incentives if participants reached their healthy goals. Adolescents preferred to earn points for reaching healthy goals, and when a participant accumulated a set number of points, they could be redeemed for free music on their smartphones.

Theme 3: Barriers to the Use of Apps

Barriers to the use of apps included frustrations that adolescents had when using the app features. Another barrier was the use of data or the slowing down of the telephone when using the app. Participants commented on their frustration with apps using data or relying on wireless Internet and waiting for the app to work. Some also mentioned that if there were too much information presented at once, it made the layout of the app confusing. Some believed that they would be less likely to use the app because of this confusion.

A few participants said that a frustration of the app would be the actual changing of their behaviors, such that the app would remind them to do exercises that would make them sore or tired. “If you’re tired in bed and it’s like, ‘Remember, you have to run 10 minutes today’ and you’re just like, ‘I don’t wanna run 10 minutes today….’”

In addition, many adolescents voiced privacy as a concern when using the apps. They explained they needed to be careful with using any identifiable information, and many reported they would use an avatar or fake name if they shared their stories in managing their weight on community forums (Table 4). It is important to note that frustrations were voiced with every app presented. Even if adolescents reported that a specific app had one of their favorite features, they still had some criticisms about the app as a whole.

Table 4.

Barriers to the use of apps

Using data/slow speed

“It’s a little slow.” “If it didn’t require data, I’d use it more often.” “It’s kinda hard because I’d use it, like, outside of my house and sometimes I don’t have my data on my phone.” “If an app heavily focuses on you need wi-fi to do it, that’s bad ‘cause not everywhere you’re gonna go, you’re gonna have wi-fi.”

Poor layout

“I don’t like to read things that much….it’s kind of like my eyes are wandering. I’m just reading the subtitle. I’m not really reading the articles.” “Well, I mean, everything looks a little cluttered … I need a search bar.” “There’s just so much stuff on that other app or this app, that it’s just kind of confusing.” “I’m a bit frustrated with it right now just trying to find some things.” “When I got stuck when I didn’t know where to go, I just started clicking around.” “It was a little bit hard to find, but after a while, I found it. Some kids may be turned off by this.” “If you get the hang of it and if you play around with it, it would be easier.”

Privacy concerns

“I don’t really talk to people on social media unless I know them.” “I don’t use my real name for anything. There’s some really creepy people out there.” “Sometimes you just wanna be safe. You don’t want everyone knowing what you’re doing … you don’t want people to know who you really are because sometimes personal information could be taken.” “I don’t know who’s out there.” “My concerns would be someone would ask me a whole bunch of different questions about where I live and just trying to stalk me.” “I never usually use my real name. I would use an avatar.”

apps, applications.

Discussion

In this study, a small number of adolescents with overweight/obesity were interested and willing to use mobile apps as tools to help them make healthy lifestyle changes and improve weight management. Mobile apps could be useful tools for adolescents to learn about healthy eating and exercise and receive social support for maintaining behavioral changes. Most of the participants were interested in downloading these apps after the interview because they wanted a tool that could be on their smartphone to remind them to be healthy, track their behaviors, or share with others their progress in managing their weight. The enthusiastic response stands in contrast to the type of oppositional behavior sometimes attributed to this age group.³⁰

These features could be a helpful resource for pediatric PCPs, especially since the United States Preventive Services Task Force has recommended that children with overweight/obesity who are 6 years and older should receive at least 26 hours of behavioral intervention within 1 year to help them improve their weight status.³¹ These app features could provide supplementary time in educating patients and keep them engaged with their goals. Smartphone apps also can help patients overcome the barriers of attending office visits and can keep adolescents connected to their PCPs between office visits. This could be helpful in rural areas, where there are fewer pediatric office visits for weight management because of a number of barriers.³²

This study found that adolescents who had used mobile apps in the past did not receive recommendations by PCPs to use specific apps. In a previous study,³³ providers were not aware of mobile apps to recommend, but reported that if they knew about weight management apps, then the majority would be interested in using them as a tool to help their patients better manage their weight.

Perhaps another reason why PCPs are not recommending mobile apps is that few have been tested for their effectiveness. In addition, many free and commercially available apps are not evidence based³⁴ or designed to promote collaboration with healthcare providers.³⁵ There are numerous available weight management apps, and we hope that our findings provide insight so that further research analyzing the efficacy of adolescent weight management using specific apps can start with adolescents’ preferred app features.

Social connection and two-way communication seemed to be a particularly interesting feature with participants. Tracking changes in healthy behaviors can assist with weight management.^36,37 As such, if patients post for others—family, friends or PCPs—to see their progress, then this feature would make patients more accountable for reaching their set goals. Two-way communication between a provider and patient via an app could be a beneficial supplement to office visits and help patients feel more support with weight management. In one study, participants reported that receiving text messages from their provider would motivate them and keep them engaged with their healthy behavioral changes.³⁸ Given the study participants’ interest in sharing their progress in reaching their healthy goals, more research is needed in this area to determine whether this communication strategy has favorable outcomes for adolescent weight management.

An important finding in this study was that adolescents had a significant concern for privacy when using mobile health apps. This is consistent with findings that 51% of teens who have downloaded apps to their smartphone or tablet have avoided certain apps due to privacy concerns, and 26% have uninstalled an app because they found it was collecting personal information they did not wish to share.¹⁶ If used as a tool to supplement weight management, then clinicians should continue to remind patients about the danger of sharing personal information on public forums and apps. Adolescents in this study said they would not disclose their real name or personal information; however, most of the adolescents wanted others (eg, family, friends, PCPs) to monitor their progress online in reaching their healthy goals. This mode of communication should be explored further to help adolescents receive support in weight management safely.

The limitations of our study include that interviews were conducted with 14 adolescents from South Carolina, and our findings may not be generalizable to other geographic regions. The small sample size is typical of qualitative studies determined when reaching a point when no new information emerges meant to describe a phenomenon to be pursued in future research.³⁹¹We also made an effort to include patients from an urban and a rural area of South Carolina, since patients in rural areas may not have access to smartphones or benefit from mobile health apps.⁴⁰ The barrier of access to smartphones did not surface during interviews because having access to a smartphone/tablet was an eligibility requirement. As such, we did not find that rurality was a barrier to app use.

Of note, this study recruited more patients from a rural area. There were fewer providers in the rural practice, and these providers may have a better relationship with their patients. Their patients may be more inclined to participate. In addition, Black patients made up 35% of the rural practice patients and 89% of the urban practice patients; however, there were fewer Black patients in our study population because a higher number of patients were enrolled from the rural office.

Conclusions

Adolescents with overweight/obesity reported they would use weight management apps if they were recommended to them, easily accessible, and similar to other non-weight management apps they have used previously. They preferred three main features of mobile health apps—obtaining nutritional information, tracking physical activity, and connecting with others—which they report would keep them engaged in developing a healthy lifestyle. Adolescents report that they would use apps less if they were difficult to operate, contain too much information, or if their privacy is a concern. This study examines adolescents’ preferred app features, which can inform future studies analyzing the effectiveness of preferred app features on adolescent weight management.

Key Points.

• Adolescents with overweight/obesity were interested and willing to use mobile health applications (apps) to help them make healthy lifestyle changes and improve weight management.

• Familiarity with similar apps and accessibility of apps on smartphones or other devices promoted weight management app use in adolescents.

• Wireless Internet, operating difficulties, or privacy concerns were barriers for weight management app use in adolescents.

• Nutritional education, physical activity tracking, and social connection were the most preferred app features of weight management apps among adolescents in the study group.