|INTRODUCTION: Poor diet and physical inactivity are prevalent and contribute to the “epidemic” of overweight and obesity in Canadian adults. Different strategies can be utilized to help individuals improve their behaviours including electronic tools, more specifically websites and mobile apps. These approaches have gained substantial recent momentum for several different reasons including: a) Internet and mobile devices and their apps are commonly used worldwide, b) they have a broad reach, c) they are versatile (e.g., can incorporate different behaviour change techniques including behaviour self-monitoring and use of goals), and d) may be able to better support behaviour change than traditional methods. Although these tools have strong potential to help improve the behaviours of individuals, and positive outcomes have been seen in research to date, there are several important research gaps that need to be addressed to better optimize use. First, much of the research on these tools has focused on use in research trial settings; few studies have been conducted on individuals using these tools more naturally, outside of this supportive setting. Second, much of the research in this area has focused on quantitative outcomes (e.g., weight loss, change in servings of fruits and vegetables); qualitative data on user and professional experiences with and perceptions of these tools is lacking. Third, numerous different behaviour change techniques, like goal setting and tracking, have been incorporated into these tools, but little information is known about naturalistic use of and experiences with such techniques in these tools. Fourth, different adjuncts (e.g., messaging, professional support) have been added to electronic tools to enhance outcomes, however, little is known about user and professional experiences and perceptions with such supports when used outside of a research trial environment. Lastly, mobile apps have the potential to help enhance the practice of Canadian dietitians, however, little information is available about use of these tools in dietetic practice. This thesis research used a combination of qualitative and quantitative research approaches through five studies that addresses these important research gaps. Studies #1, #2, and #3 evaluated Dietitians of Canada’s web-based eaTracker® (http://www.eaTracker.ca/) “My Goals” feature, as well as dietitian contact-centre support and motivational messaging provided for Ontario users of this tool. The My Goals feature allows individuals to set goals (“ready-made” Specific – Measurable – Achievable – Realistic – Time related goals or “write your own” goals) and track goal related progress using the My Goals Tracker. EatRight Ontario (ERO), an organization that provides free nutrition assistance by toll-free call, email and website for Ontario, Canada residents, added additional adjunct supports for Ontario My Goals users including the opportunity to consult with an ERO contact centre dietitian about their goals, and goal-related motivational email and website delivered messaging. Study #4 examined adult user experiences with and perceptions of nutrition mobile apps for weight management when used outside of a research trial environment. Study #5 examined use of mobile device apps in Canadian dietetic practice.
METHODS: The University of Waterloo Office of Research Ethics provided approval for all studies. Study #1: A dataset containing anonymous data on all goals set with the eaTracker® My Goals feature from December 6, 2012 to April 28, 2014 by users ≥19 years of age from Ontario and Alberta, Canada, with active eaTracker® accounts was acquired from Dietitians of Canada. This dataset contained information on: a) self-reported user demographics, b) goals set with the feature, and c) My Goals Tracker use information. “Write your own” goals were categorized by topic area and specificity. Descriptive statistics were used to summarize demographics, goals, and tracker use. Study #2 and #3: eaTracker® users from Ontario and Alberta, Canada who had set a goal with the My Goals feature at least 30 days previously (and for Ontario users, they had to have been signed up to receive ERO motivational messaging for at least 30 days) were recruited using a pop-up box on the eaTracker® website. Recruited participants completed a one-on-one semi-structured qualitative interview in-person, by phone or online, on the My Goals feature and ERO adjunct supports. ERO dietitians were also interviewed, having been recruited via ERO administration. Audio recorded interviews were transcribed. Transcripts were coded and codes were organized into categories using NVivo version 10 (QSR International, Doncaster, Australia). Study #4: Healthy adults who had been using publicly available mobile apps for nutrition behaviour change to manage body weight not for the purpose of a research trial were recruited via social media, posters, and word of mouth to complete a one-on-one in-person semi-structured interview. Transcribed interviews were coded, and codes were organized into categories and subcategories using NVivo 10. Study #5: A survey on diverse aspects of mobile app use in dietetic practice was drafted with different question types (n=49 possible questions), and mounted on the SurveyMonkey® (SurveyMonkey, Palo Alto, California) website following pre-testing by volunteer dietetic interns and dietitians. Dietitians of Canada promoted the final survey to dietitians from January 2012-April 2012 via their monthly member e-newsletter. Quantitative data were analyzed using descriptive statistics, and open-ended questions were coded, and underwent thematic analysis.
RESULTS: Study #1: Overall, n=16,511 goal entries (75.4% ready-made; 24.6% write your own) were included for analysis. These goals were set by n=8,067 adult users 19-85 years of age (83.3% female; mean age 41.1±15.0 years, mean body mass index (BMI) 28.8±7.6kg/m2). Of all included ready-made goals, 33.1% were from the “Managing your Weight” category. Of “write your own” goal entries, 42.3% were solely distal goals (most related to weight management); 38.6% addressed nutrition behaviour change (16.6% had unspecific general eating goals); 18.1% addressed physical activity behaviour change (47.3% without information on exercise amount and type). Many “write your own” goals were poor quality (e.g., non-specific) and likely unrealistic (e.g., no sugar). Less than 10% of goals were tracked. Study #2: Participants said goal setting for nutrition and physical activity behaviour change was beneficial, yet it was difficult to follow through with goals. In general, they showed enthusiasm for the My Goals concept, but the current feature had several functional limitations. Suggestions were provided to improve the My Goals feature and that could also be used for the development of future goal setting and tracking tools. Study #3: Although participants were enthusiastic about having the ability to consult with dietitians about their goals, no interviewed Ontario My Goals users had contacted ERO dietitians for goal-related assistance, and ERO dietitians reported encountering few to no individuals seeking this assistance while using My Goals. Limited knowledge of this service was the main explanation for this finding. Participants reported mixed thoughts and preferences on motivational messages (ranging from being helpful supports to not being helpful or wanted). Numerous suggestions were provided to improve both contact centre dietitian support and motivational messaging in the future. Study #4: Participants reported using a variety of apps to help them change their nutrition behaviours; MyFitnessPal® (MyFitnessPal, San Francisco, California) was the most popular. In general, participants reported using them without any professional assistance. Most participants were enthusiastic about these tools; however, challenges were reported. Aspects of the experience users had with using these apps can be divided into the following categories: a) data entry, b) accountability, feedback and progress, c) technical and app-related factors, d) personal factors, and e) obsession. Data entry was done throughout the day for most participants; however, some waited until the end of the day to enter data and others used apps to pre-plan their food intake. Participants liked large food databases; however, sometimes foods were difficult to find. Difficulties estimating portion size and entering mixed dishes and restaurant foods were also reported. Barcode scanners, and data entry shortcuts (e.g., favourites, multi-add) were well liked and used often. Technical concerns (e.g., long loading time) were encountered by some users which sometimes caused them to end use. Personal factors (e.g., self-motivation, privacy, knowledge) also affected use. Some female participants mentioned that apps could promote an obsession with dietary intake recording and calories. Study #5: In total, 139 dietitians answered some questions and 118 completed the survey. Mobile app use in dietetic practice was reported by 57.3%, and 54.2% reported that they had a client ask about or use a nutrition/food app. Just under half of all respondents (40.5%) had recommended nutrition/food apps to clients. Although respondents felt positively about mobile apps, several challenges were mentioned. From open-ended question responses, three themes emerged regarding factors that can affect dietitians’ use of apps and whether they recommend them to clients: mobile device and app factors (access to information/tools, content quality, ease of use, accessibility/compatibility, and cost), personal factors (knowledge, interest, suitability, and willingness/ability to pay), and workplace factors.
CONCLUSION: Through evaluating the experiences and perceptions of those using a range of electronic tools and features to support nutrition and physical activity behaviour change outside of a research trial setting, this research provides in-depth information on emerging technology use for this purpose. Not only does this research have direct application to improve Dietitians of Canada’s eaTracker® tools and associated supports, it can also be used to inform the next generation of apps and other electronic tools. This thesis research also provides information relevant to dietitians and other health professionals who work with individuals using electronic tools to support healthier nutrition and physical activity behaviours and body weights.