Published on 14.05.15 in Vol 17, No 5 (2015): May
Behavior Change Techniques in Popular Alcohol Reduction Apps: Content Analysis
Background: Mobile phone apps have the potential to reduce excessive alcohol consumption cost-effectively. Although hundreds of alcohol-related apps are available, there is little information about the behavior change techniques (BCTs) they contain, or the extent to which they are based on evidence or theory and how this relates to their popularity and user ratings.
Objective: Our aim was to assess the proportion of popular alcohol-related apps available in the United Kingdom that focus on alcohol reduction, identify the BCTs they contain, and explore whether BCTs or the mention of theory or evidence is associated with app popularity and user ratings.
Methods: We searched the iTunes and Google Play stores with the terms “alcohol” and “drink”, and the first 800 results were classified into alcohol reduction, entertainment, or blood alcohol content measurement. Of those classified as alcohol reduction, all free apps and the top 10 paid apps were coded for BCTs and for reference to evidence or theory. Measures of popularity and user ratings were extracted.
Results: Of the 800 apps identified, 662 were unique. Of these, 13.7% (91/662) were classified as alcohol reduction (95% CI 11.3-16.6), 53.9% (357/662) entertainment (95% CI 50.1-57.7), 18.9% (125/662) blood alcohol content measurement (95% CI 16.1-22.0) and 13.4% (89/662) other (95% CI 11.1-16.3). The 51 free alcohol reduction apps and the top 10 paid apps contained a mean of 3.6 BCTs (SD 3.4), with approximately 12% (7/61) not including any BCTs. The BCTs used most often were “facilitate self-recording” (54%, 33/61), “provide information on consequences of excessive alcohol use and drinking cessation” (43%, 26/61), “provide feedback on performance” (41%, 25/61), “give options for additional and later support” (25%, 15/61) and “offer/direct towards appropriate written materials” (23%, 14/61). These apps also rarely included any of the 22 BCTs frequently used in other health behavior change interventions (mean 2.46, SD 2.06). Evidence was mentioned by 16.4% of apps, and theory was not mentioned by any app. Multivariable regression showed that apps including advice on environmental restructuring were associated with lower user ratings (Β=-46.61, P=.04, 95% CI -91.77 to -1.45) and that both the techniques of “advise on/facilitate the use of social support” (Β=2549.21, P=.04, 95% CI 96.75-5001.67) and the mention of evidence (Β=1376.74, P=.02, 95%, CI 208.62-2544.86) were associated with the popularity of the app.
Conclusions: Only a minority of alcohol-related apps promoted health while the majority implicitly or explicitly promoted the use of alcohol. Alcohol-related apps that promoted health contained few BCTs and none referred to theory. The mention of evidence was associated with more popular apps, but popularity and user ratings were only weakly associated with the BCT content.
J Med Internet Res 2015;17(5):e118
Excessive alcohol use causes approximately 3.3 million deaths each year, and more than 5% of the global burden of disease is attributable to its consumption . Brief interventions delivered by health care workers to hazardous drinkers are effective [ ]. However, there is little understanding of their mechanisms of action [ ], and barriers to their delivery such as lack of time, training, and financial resources mean they have limited reach [ , ].
Mobile phones offer the potential to reduce these barriers as they are relatively cheap, accessible to users, and deliver support when and where needed. Mobile phone apps for mobile health (mHealth) enable disease monitoring, management, and education; improve health behavior assessment; and facilitate more frequent user-to-user or practitioner-to-user communication [- ]. Thousands of mHealth apps are available; as of June 2013, there were over 40,000 mHealth apps in the US English-language iTunes Store alone [ ]. Approximately 20% of smartphone users have downloaded an mHealth app [ ]; this figure is expected to rise as both smartphone ownership and the number of apps increase. According to industry estimates, 1.7 billion smartphone users worldwide will have downloaded an mHealth app by 2018 [ ].
Smartphone use is increasing rapidly among young people, but older people are also using apps in increasing numbers . App-delivered interventions to reduce excessive alcohol consumption could potentially be targeted at a range of age groups, as younger people tend to drink more heavily but older people tend to drink more regularly [ ].
Despite the proliferation of mHealth apps, there has been little research investigating their mechanisms of action or efficacy and they are often developed without reference to evidence base or theory . Reviews of apps for smoking cessation [ ], weight loss [ - ], diabetes management [ ], healthy eating and physical activity [ , ], breast disease management [ ], and melanoma detection [ ] have found the majority fail to conform to guidelines, lack evidence-based content, and/or provide inaccurate information. Concern about the content of mHealth apps has led to calls for regulation to improve patient safety [ , ].
Moreover, the most popular apps—as defined by the approximate number of installations on the Google Play store or by their position in the search results in the iTunes Store—have been found to contain fewer evidence-based techniques , lower levels of adherence to guidelines [ ], or information that may encourage risky behavior [ ] than less popular apps. User ratings are a different measure of popularity and reflect a user’s judgment about the quality of the app (eg, an app may be highly rated but used by only a small number of people). User ratings have been found to be associated with high levels of adherence to guidelines in smoking cessation apps [ ], although not in weight loss [ ] or physical activity apps [ ].
A review of 767 alcohol apps available in the US version of the iTunes Store found that 71% facilitated the use of alcohol and 29% aimed to reduce its consumption , though many of the alcohol reduction apps simply attempted to measure a user’s blood alcohol content (BAC). A review of 384 BAC apps available in the Australian iTunes and Google Play stores found that most were inaccurate, with some purporting to measure BAC by asking users to blow into the microphone, and only 11% of all the apps examined had an alcohol reduction focus [ ].
Of the US and Australian alcohol-reduction apps identified in previous studies [, ], little is known about their potential active ingredients and mechanisms of action. A useful method for describing the potentially active ingredients of apps is to assess the behavior change techniques (BCTs) they contain [ - ]. A BCT is “an observable, replicable, and irreducible component of an intervention designed to alter or redirect causal processes that regulate behavior; that is, a technique is proposed to be an ‘active ingredient’ (eg, feedback, self-monitoring, and reinforcement)” (p. 82, [ ]).
A taxonomy of 42 BCTs to reduce excessive alcohol consumption has been developed from guidance documents and treatment manuals identified by expert consultation . The taxonomy has been reliably applied to identifying BCTs in brief alcohol interventions, and meta-regression revealed that those that included self-monitoring were associated with larger effect sizes [ ]. Similar taxonomies have been used to reliably identify BCTs contained in physical activity and dietary apps [ , ].
An additional aim of this study was to identify whether there were BCTs widely used in domains other than alcohol consumption that could be considered for alcohol apps. Analysis of the BCTs used in 40 published descriptions of behavior change interventions to prevent illness, improve illness management, or improve the behaviors of health care professionals found that 22 of a possible 93 BCTs were frequently used. A comparison with those used in alcohol apps would indicate potentially useful BCTs not frequently used in alcohol apps.
The current study should yield benefits for research and practice. Coding alcohol apps for BCTs allows (1) researchers to identify BCTs and establish which ones are based on theory and/or evidence and to conduct evaluations in terms of BCTs, (2) users to be better informed about which BCTs are present and enable them to choose ones suited to their needs, (3) health care practitioners to make more informed recommendations to patients , and (4) app developers to make decisions about which BCTs to include.
This study builds on previous work [, ] by providing an up-to-date estimate of the relative prevalence of alcohol-related apps available in the United Kingdom that focus on reducing excessive alcohol consumption and by coding those apps for their component BCTs [ ]. We also explored associations between the presence of BCTs, the mention of theory or evidence, and the popularity and user ratings of the app.
The research questions addressed by this study are (1) What proportion of alcohol-related apps available in the UK version of the iTunes and Google Play stores focus on alcohol reduction?, (2) Which BCTs are contained within alcohol-related apps focusing on alcohol reduction?, (3) To what extent do alcohol-related apps focusing on alcohol reduction use BCTs commonly found in other types of behavior change intervention?, and (4) What are the associations between the presence of BCTs, the mention of theory or evidence, and the popularity and user ratings of the apps?
Search Strategy and Data Extraction
Alcohol-related apps were identified by searching the UK versions of the iTunes and Google Play stores in April and May 2014 for the terms “alcohol” and “drink”. The following data were extracted from the first 200 results found for each term in each app store (4 x 200): time and location of search, app name, developer name, ranking in the search results, cost, and classification. We considered 200 search results for each search term comprehensive as users rarely examine search results thoroughly .
Duplicate apps were removed from the 800 search results and the unique apps were classified as either alcohol reduction (apps that aim to reduce drinking-related behavior and those that track consumption), entertainment (drinking games, cocktail recipes, bar finders); BAC measurement; or other (apps not about alcohol, apps not in English, information for employers, etc).
Of the 91 alcohol reduction apps, we installed, examined, and coded all 51 free apps as users prefer apps that are free to download . However, 10 paid apps were installed, examined, and coded as a sensitivity check of the BCTs included. The remaining paid apps (n=15), apps that could not be installed (n=5), or those that focused on hypnosis (n=10) were excluded (see ). Included apps were coded for the presence of BCTs [ ], mention of theory, mention of evidence, number of installations, and user ratings. Ratings were taken from all versions of the app in the iTunes store (rather than the current version). We did not base our coding on any other information (such as descriptions in the app stores or on Web pages, or within developers’ protocols or published papers).
Behavior Change Technique Coding
The taxonomy of BCTs to reduce excessive alcohol consumption and the associated coding manual were used for our evaluation . The coding manual includes definitions and examples of BCTs and guidelines for identifying them in intervention descriptions. For each app, BCTs were coded as 0: no evidence of BCT, 1: BCT present in all probability but evidence unclear; and 2: BCT present beyond all reasonable doubt and clear evidence. For all analyses, the presence of a BCT was dichotomized, with only those receiving a “2” being classified as containing the BCT. The BCT “build general rapport” was excluded from coding because it could not be appropriately coded for a digital intervention.
The coding manual was used independently by 2 trained coders (DC and CG) to code 11 of the included apps. There was “outstanding” agreement: prevalance and bias adjusted kappa (PABAK)=.89, kappa=.65  for this first round of coding. Discrepancies were discussed and the coding guidelines were refined. After the coding manual was updated, the remaining apps were coded by 1 coder (DC) with 15% also coded by the second coder (CG) to assess rater drift. There was “outstanding” agreement for the subsequent ratings of the eight apps coded by both raters (PABAK=.89, kappa=.81 [ ]).
Of the 93 BCTs described by a general taxonomy of behavior change (BCTTv1) , 22 have been found to be frequently used in a variety of health behavior change interventions [ ]. In order to establish the extent to which the included apps contained these BCTs, 1 coder (DC) and an independent behavior change expert mapped the 22 frequently used BCTs to the alcohol taxonomy [ ]. This allowed us to determine the prevalence of those BCTs in these apps.
The full content of the apps was coded. Alcohol consumption spanning numerous days was entered in order to determine if the app included graphs that displayed progress over time. If the app was tailored on the basis of personal details, the characteristics of a female alcohol consumer in the United Kingdom drinking moderately above guidelines were used (30 years, consumed 16 units of alcohol over 3 days in the previous week). Theory was coded if the app made reference to theory as a factor informing its development. Evidence was coded if the app made reference to empirical evidence relating to behavior change. Apps were coded on an iPhone running iOS7 and a Samsung Galaxy S3 running Android 4.3.
Popularity and User Ratings
The popularity of apps was operationalized as the overall number of ratings received. User ratings of the apps were operationalized by assessing the proportion of ratings that were four or five star and calculating the associated lower 95% confidence interval (CI). Mean ratings were not used because they do not reflect the uncertainty associated with a very small number of ratings . For example, an app with 2 five-star reviews and no other reviews would receive a mean rating of 5 and an app with 900 five-star reviews and 100 one-star reviews would receive a mean rating of 4.6. Whereas, if using a lower bound CI, an app with 2 five-star reviews would have a lower bound CI of .34, and an app with 900 five-star reviews and 100 one-star reviews would have a lower bound CI of .88. This approach has been adopted by websites such as reddit and Yelp, which depend on accurately ranking user ratings [ , ].
All statistical analyses were conducted using SPSS version 20.0. Frequencies, percentages, and associated 95% CIs were calculated for the categories of alcohol-related apps (alcohol reduction, entertainment, blood alcohol content, other), for each of the 41 BCTs, and for the mention of theory or the mention of evidence contained within the alcohol reduction apps. To assess interrater reliability, kappa and PABAK were calculated. PABAK is an adjusted kappa statistic that accounts for coders agreeing on the presence or the absence of codes . PABAK was used in addition to Cohen’s kappa, which only accounts for coders agreeing on the presence of codes.
We examined (1) all BCTs infor their frequency in alcohol reduction apps, (2) associations between the presence of BCTs and the mention of theory or evidence listed in with the popularity of the app in a series of univariable logistic regressions, and (3) the independent association after mutual adjustment for all variables listed in in a multivariable logistic regression. BCTs that were present in two or fewer apps were excluded. We repeated similar analyses to examine the univariable and multivariable associations between the presence of BCTs and the mention of theory or evidence listed in with the user ratings.
Of the 800 apps returned from the searches, 662 unique apps were identified (see). Of these, 13.7% were classified as alcohol reduction (91/662, 95% CI 11.3-16.6), 53.9% entertainment (357/662, 95% CI 50.1-57.7), 18.9% blood alcohol content measurement (125/662, 95% CI 16.1-22.0), and 13.4% other (89/662, 95% CI 11.1-16.3). A total of 61 apps were coded: all 51 free apps and the first 10 paid apps found in the search results. The remaining paid apps (n=15), apps that could not be installed (n=5), and those that focused on hypnosis (n=10) were excluded.
Behavior Change Techniques in Alcohol Reduction Apps
A sensitivity check indicated that the number and type of BCTs in free and paid apps was broadly similar, so they were treated as a single group (data not shown). The mean number of BCTs from the alcohol taxonomy  used in apps was 3.56 (SD 3.39, median 2). Seven apps did not include any BCTs and 30 apps (49.2%) included only one, two, or three BCTs. Five apps included 10 or more BCTs. The maximum number of BCTs included was 13 (n=3), and 26 BCTs were used in at least one app.
The frequency with which BCTs were included by different apps is shown in. The most frequent BCTs were “facilitate self-recording” (54.1%, 33/61), “provide information on consequences of excessive alcohol use and drinking cessation” (42.6%, 26/61), “provide feedback on performance” (41.0%, 25/61), “give options for additional and later support” (24.6%, 15/61), and “offer/direct towards appropriate written materials” (23.0%, 14/61).
|15||Facilitate self-recording||33 (54.1)|
|1||Provide information on consequences of excessive alcohol use and drinking cessation||26 (42.6)|
|3||Provide feedback on performance||25 (41.0)|
|22||Give options for additional and later support||15 (24.6)|
|32||Offer/direct towards appropriate written materials||14 (23.0)|
|23||Tailor interactions appropriately||13 (21.3)|
|2||Boost motivation and self‐efficacy||9 (14.8)|
|14||Prompt review of goals||8 (13.1)|
|4||Provide rewards contingent on successfully reducing excessive alcohol use/abstaining||8 (13.1)|
|13||Facilitate goal setting||7 (11.5)|
|33||Provide information on withdrawal symptoms||6 (9.8)|
|17||Advise on environmental restructuring||5 (8.2)|
|42||Behavior substitution||5 (8.2)|
|10||Facilitate barrier identification and problem solving||4 (6.6)|
|11||Facilitate relapse prevention and coping||4 (6.6)|
|20||Advise on avoidance of social cues for drinking||4 (6.6)|
|21||Advise on/facilitate use of social support||4 (6.6)|
|6||Prompt commitment from the user there and then||4 (6.6)|
|12||Facilitate action planning/know how to help identify relapse triggers||3 (4.9)|
|25||Assess current and past drinking behavior||3 (4.9)|
|5||Provide normative information about others’ behavior and experiences||3 (4.9)|
|16||Change routine||2 (3.3)|
|24||Emphasize choice||2 (3.3)|
|37||Provide reassurance||2 (3.3)|
|7||Provide rewards contingent on effort or progress||2 (3.3)|
|8||Identify reasons for wanting and not wanting to reduce excessive alcohol use||2 (3.3)|
|18||Set graded tasks||1 (1.6)|
|26||Assess current readiness and ability to reduce excessive alcohol use||1 (1.6)|
|31||Explain expectations regarding treatment programme||1 (1.6)|
|9||Explain the importance of abrupt cessation||1 (1.6)|
|19||Advise on conserving mental resources||0 (0)|
|27||Assess past history of attempts to reduce excessive alcohol use||0 (0)|
|28||Assess withdrawal symptoms||0 (0)|
|30||Elicit and answer questions||0 (0)|
|34||Use reflective listening||0 (0)|
|35||Elicit user views||0 (0)|
|36||Summarize information/confirm user decisions||0 (0)|
|38||Model/demonstrate the behavior||0 (0)|
|39||Prompt use of imagery||0 (0)|
|40||Motivational interviewing||0 (0)|
|41||General communication skills training||0 (0)|
Eleven BCTs were not used in any app: “advise on conserving mental resources”, “assess past history of attempts to reduce excessive alcohol use”, “assess withdrawal symptoms”, “elicit and answer questions”, “use reflective listening”, “elicit user views”, “summarize information/confirm user decisions”, “model/demonstrate the behavior”, “prompt use of imagery”, “motivational interviewing”, and “general communication skills training”.
Behavior Change Techniques Frequently Found in Other Interventions and Used in Alcohol Apps
Of the 22 BCTs frequently found in other health behavior change interventions, the mean number included in alcohol-reduction apps was 2.46 (SD 2.06, median 2). Of these 22, the five most often included in alcohol apps were “facilitate self-recording” (54.1%, 33/61), “provide information on consequences of excessive alcohol use and drinking cessation” (42.6%, 26/61), “provide feedback on performance” (41.0%, 25/61), “give options for additional and later support” (24.6%, 15/61), and “offer/direct towards appropriate written materials” (23.0%, 14/61). Three of the BCTs frequently found in other health behavior change interventions were not used in any app “motivational interviewing”, “use reflective listening”, and “model/demonstrate the behavior”.
Associations Between Behavior Change Techniques, Theory, and Evidence With Popularity and User Ratings
The mean user rating for apps was 2.64 (SD 1.71), and the mean number of ratings was 234.46 (SD 1272.08). Evidence was mentioned in 16.4% of apps (n=10), most usually evidence about the recommended guidelines for the consumption of alcohol. Theory was not mentioned by any app.
The BCT “prompt review of goals” (B=0.41, P=.001, 95% CI 11.88-44.79) was positively associated with user ratings in univariable regression models (); no other significant associations between BCTs and user ratings were found. In multivariable linear regression models, the only significant association was a negative one: apps that advised on environmental restructuring had marginally lower user ratings (Β=-46.61, P=.04, 95% CI -91.77 to -1.45).
|BCT||Unadjusted Β (CI)||Adjusted B (CI)|
|1||Provide information on consequences of excessive alcohol use and drinking cessation||0.08 (-8.59 to 15.96)||-6.54 (-32.64 to 19.56)|
|2||Boost motivation and self‐efficacy||0.13 (-8.78 to 25.29)||17.88 (-9.77 to 45.53)|
|3||Provide feedback on performance||0.23 (-1.25 to 22.86)||-14.28 (-43.21 to 14.65)|
|4||Provide rewards contingent on successfully reducing excessive alcohol use/abstaining||0.18 (-5.25 to 30.23)||4.73 (-25.16 to 34.62)|
|6||Prompt commitment from the user there and then||0.18 (-7.21 to 41.18)||-31.96 (-83.87 to 19.94)|
|10||Facilitate barrier identification and problem solving||-0.03 (-27.15 to 22.03)||-62.14 (-139.39 to 15.12)|
|11||Facilitate relapse prevention and coping||-0.17 (-39.96 to 8.55)||-17.62 (-94.96 to 59.71)|
|13||Facilitate goal setting||0.19 (-4.96 to 32.57)||15.19 (-16.26 to 46.64)|
|14||Prompt review of goals||0.41 (11.88 to 44.79)b||24.34 (-3.67 to 52.34)|
|15||Facilitate self-recording||0.17 (-4.01 to 20.07)||-0.92 (-27.75 to 25.91)|
|17||Advise on environmental restructuring||-0.1 (-30.69 to 13.48)||-46.61 (-91.77 to -1.45)b|
|20||Advise on avoidance of social cues for drinking||0.06 (-18.82 to 30.28)||18.98 (-38.64 to 76.61)|
|21||Advise on/facilitate use of social support||0.05 (-19.66 to 29.46)||2.39 (-42.95 to 47.73)|
|22||Give options for additional and later support||0.05 (-11.55 to 16.7)||-2.04 (-44.97 to 40.89)|
|23||Tailor interactions appropriately||0.23 (-1.16 to 27.76)||-0.89 (-26.32 to 24.54)|
|32||Offer/direct towards appropriate written materials||0.02 (-13.51 to 15.44)||-16.25 (-50.57 to 18.07)|
|33||Provide information on withdrawal symptoms||-0.06 (-25.39 to 15.42)||-6.91 (-54.04 to 40.22)|
|42||Behavior substitution||-0.07 (-27.65 to 16.65)||-5.25 (-64.82 to 54.32)|
|Total BCTs||0.16 (-0.66 to 2.91)||6.29 (-13.28 to 25.87)|
|Mention of evidence||0.22 (-2.25 to 29.85)||18.15 (-3.45 to 39.74)|
aBCTs only included for analysis if present in more than two apps. The adjusted models included all variables listed in this table.
The mention of evidence (B=0.26, P=.04, 95% CI 24.28-1739.31) was positively associated with the popularity of the apps in univariable regression models (). In a multivariable linear regression models, both “advise on/facilitate the use of social support” (Β=2549.21, P=.04, 95% CI 96.75-5001.67) and the mention of evidence (Β=1376.74, P=.02, 95% CI 208.62-2544.86) were positively associated with popularity.
|BCT||Unadjusted B (CI)||Adjusted B (CI)|
|1||Provide information on consequences of excessive alcohol use and drinking cessation||0.19 (-155.79 to 1148.02)||906.92 (-504.77 to 2318.61)|
|2||Boost motivation and self-efficacy||-0.06 (-1143.07 to 706.91)||-228.05 (-1723.82 to 1267.72)|
|3||Provide feedback on performance||0.2 (-138.23 to 1170.96)||410.01 (-1154.91 to 1974.93)|
|4||Provide rewards contingent on successfully reducing excessive alcohol use/abstaining||-0.03 (-1101.77 to 844.34)||-1362.93 (-2979.54 to 253.69)|
|6||Prompt commitment from the user there and then||-0.05 (-1563.56 to 1089.02)||-644.43 (-3452.1 to 2163.25)|
|10||Facilitate barrier identification and problem solving||-0.05 (-1570.16 to 1082.25)||-2150.59 (-6329.64 to 2028.46)|
|11||Facilitate relapse prevention and coping||-0.05 (-1574.65 to 1077.64)||2175.79 (-2007.23 to 6358.81)|
|13||Facilitate goal setting||0.05 (-849.23 to 1210.96)||828.87 (-872.37 to 2530.11)|
|14||Prompt review of goals||0.04 (-838.87 to 1107.13)||-751.26 (-2266.15 to 763.63)|
|15||Facilitate self-recording||0.15 (-264.74 to 1038.84)||547.11 (-904.17 to 1998.39)|
|17||Advise on environmental restructuring||-0.05 (-1441.99 to 950.81)||-1189.63 (-3632.18 to 1252.92)|
|20||Advise on avoidance of social cues for drinking||-0.05 (-1564.35 to 1088.21)||-2799.6 (-5916.7 to 317.49)|
|21||Advise on/facilitate use of social support||-0.05 (-1562.23 to 1090.37)||2549.21 (96.75 to 5001.67)b|
|22||Give options for additional and later support||0.2 (-149.92 to 1344.47)||-61.18 (-2383.46 to 2261.1)|
|23||Tailor interactions appropriately||-0.06 (-984.06 to 618.26)||-778.78 (-2154.21 to 596.65)|
|32||Offer/direct towards appropriate written materials||0.22 (-115.64 to 1410.65)||666.27 (-1190.03 to 2522.58)|
|33||Provide information on withdrawal symptoms||-0.06 (-1355.21 to 848.07)||-1868.23 (-4417.4 to 680.94)|
|42||Behavior substitution||-0.05 (-1440.49 to 952.36)||-1442.94 (-4665.2 to 1779.31)|
|Total BCTs||0.07 (-70.01 to 124.48)||150.73 (-908.13 to 1209.58)|
|Mention of evidence||0.26 (24.28 to 1739.31)b||1376.74 (208.62 to 2544.86)b|
aBCTs only included for analysis if present in more than two apps. The adjusted models included all variables listed in this table.
A review of 662 alcohol-related apps in the UK version of the iTunes and Google Play stores found that more than half were classified as entertainment apps that promoted drinking, 19% were BAC calculators, and 14% had an alcohol reduction focus. This is consistent with findings on alcohol-related apps available in the United States and Australian app stores [, ] and indicates that potential app users who search for terms such as “alcohol” will be primarily exposed to apps encouraging increased alcohol consumption.
The BCTs most often used in alcohol reduction alcohol apps were (1) “facilitate self-recording” (included in 54% of apps), (2) “provide information on consequences of excessive alcohol use” (43%), (3) “provide feedback on performance” (41%), (4) “give options for additional and later support” (25%), and (5) “offer/direct towards appropriate written materials” (23%). The second, fourth, and fifth of these are information-based. This finding may indicate a missed opportunity for app developers, as interventions that require interaction from participants are associated with increased amounts of behavior change than interventions that passively present information .
Behavior change interventions are often complex and consist of a number of BCTs , which may interact additively or synergistically. For example, Control Theory [ ] posits that goal-setting, feedback/self-monitoring, action planning, and goal review have synergistic effects. Interventions using a group of these techniques have been found to be more effective than interventions that used only one [ - ]. In alcohol reduction apps, “facilitate self-recording” and “provide feedback on performance” were found to be frequently used BCTs. However, other theory-linked BCTs were often not included: “prompt review of goals” was used in only 13% of apps, “facilitate goal setting” in 12%, and “facilitate action planning” in 5%.
The number of apps prompting the review of behavioral goals was greater than the number that facilitated goal setting, as in many cases apps assumed a user’s behavioral goal was to get their drinking below recommended daily or weekly guidelines and displayed a graph to indicate how current levels of drinking compared to guidelines. Apps that facilitated goal setting allowed users to set their own goals, for example, to have a set number of non-drinking days each week. People are motivated by different types of goals  and self-set goals tend to result in greater commitment to goal achievement than assigned goals [ ]. Together these studies suggest that apps that allow users to set their own goals and review their performance against them would be more successful, but only three apps met this criteria.
The mean number of BCTs from the alcohol taxonomy  included in the reviewed apps was less than four. Five apps included more than 10 BCTs, three of which were book or pamphlet-type apps that passively provided information or advice. More BCTs does not necessarily equate to more effective interventions; interventions that targeted lower-income groups to reduce smoking or increase physical activity and/or healthy eating were found to be more effective when they contained fewer BCTs [ ]. Other reviews have found a positive relationship between the number of BCTs and weight loss [ ] and that health behavior change interventions that included more BCTs tended to have larger effect sizes [ ].
The relatively low number of BCTs used in the majority of apps in this study suggests there is scope to investigate whether including more BCTs could increase effectiveness and additionally, whether BCTs found to be effective when delivered face-to-face could be effective when delivered digitally. For example, “provide normative information about others’ behavior and experiences” has been found effective in reducing alcohol consumption when delivered digitally [, ] but was used in less than 5% of the apps reviewed in the current study. “Motivational interviewing” is another frequently used BCT and has been used in a Web-based intervention to reduce alcohol consumption [ ] indicating the possibility for it to be delivered digitally, but no apps included this technique. It will be important to establish whether any BCTs found to be effective in other modes of delivery generalize to app-based interventions.
The 22 BCTs frequently found in other health behavior change interventions  were rarely used in alcohol apps (mean 2.5). Social support is the BCT most frequently found in other interventions but was only used in 7% of alcohol apps. “Facilitate action planning” is a frequently used BCT in other interventions but was included in less than 5% of apps. Action planning has been found effective when combined with feedback [ ], but none of the apps in this study included both techniques. This finding suggests that developers of alcohol apps may benefit from looking across other domains. In doing so, it is useful to draw on theory to guide the selection of BCTs for any given intervention.
The BCT “prompt review of goals” was positively associated with user ratings in univariable models, and “advise on environmental restructuring” was negatively associated with user ratings in multivariable models. The mention of evidence was positively associated with the popularity of the app in univariable models, and both the mention of evidence and “advise on/facilitate the use of social support” were positively associated with popularity in multivariable models. Apps that mentioned evidence usually referred to evidence relating to the recommended guidelines for consumption rather than evidence about the approach to behavior change adopted by the app. No app mentioned theory.
The current study provided relatively little evidence of association between BCTs, mention of theory or evidence, and the popularity or user ratings of apps. However, the failure to identify evidence of associations should not be taken as evidence that there are not true associations. The relatively small number of alcohol reduction apps available for analysis meant the study was exploratory and had only limited power.
It may be that other BCTs are associated with user ratings and popularity, but the large variation in the design, complexity, and functionality of apps and the contexts in which use occurs may be masking such associations . An app with a large number of BCTs could be poorly built and so result in a poor user experience, negative ratings, and few downloads, whereas an app with few BCTs could be well built and result in a good user experience, positive ratings, and increased downloads. Careful experimental work in factorial designs is required to isolate and test the impact of BCTs and other app characteristics.
Strengths and Limitations
While previous studies have examined the type of alcohol-related apps that are available, this is the first to our knowledge to have examined the BCTs present in alcohol apps with an alcohol reduction focus. Documenting their content allows researchers to refine their future evaluations in terms of active ingredients and may help users to be better informed. It may also allow for future regulation of apps to be facilitated [, ].
This study has several limitations. First, the presence of BCTs was coded but not their “dose” , that is, their intensity and whether or how often it was repeated, nor the quality with which it was delivered [ ], which is likely to influence the degree with which it was engaged with by users. Engagement with a BCT is important if behavior change is to occur, but many digital interventions experience high levels of attrition [ ]; more understanding of the ways in which users engage with mHealth apps is required. Second, the mHealth market is constantly evolving. New apps are added on a regular basis, and both Google and Apple frequently change their algorithms for returning search results. Therefore, these findings should be seen as representing a snapshot in time. Finally, the BCTs were identified by a taxonomy developed for face-to-face rather than digital interventions [ ]. While an acceptable interrater reliability was established, the list may not be exhaustive and a similar method designed specifically for digital interventions is needed.
While a minority of alcohol-related apps promoted health, the majority implicitly or explicitly promoted the use of alcohol. Alcohol-related apps that focused on alcohol reduction usually contained few BCTs or few BCTs frequently found in other interventions, and their popularity or user ratings were only weakly related to their BCT content. None of the apps mentioned theory, and the few apps that mentioned evidence usually referred to evidence about guidelines. The popularity of these apps suggests that users may value content that makes explicit reference to evidence.
David Crane is funded by the National Institute for Health Research (NIHR)’s School for Public Health Research (SPHR). The views expressed are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health.
Conflicts of Interest
JB has received an unrestricted research grant from Pfizer related to the surveillance of smoking cessation trends. RW has received research funding and undertaken consultancy for companies that manufacture smoking cessation medications.
Multimedia Appendix 1
Taxonomy of 42 BCTs used to treat excessive alcohol use. Tailored for apps.PDF File (Adobe PDF File), 23KB
- World Health Organization. 2014. Global status report on alcohol and health 2014 URL: http://apps.who.int/iris/handle/10665/112736 [accessed 2014-11-19] [WebCite Cache]
- Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007(2):CD004148. [CrossRef] [Medline]
- Gaume J, McCambridge J, Bertholet N, Daeppen JB. Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review. Front Psychiatry 2014;5:108 [FREE Full text] [CrossRef] [Medline]
- Kaner E. Brief alcohol intervention: time for translational research. Addiction 2010 Jun;105(6):960-1; discussion 964. [CrossRef] [Medline]
- Heather N, Dallolio E, Hutchings D, Kaner E, White M. Implementing routine screening and brief alcohol intervention in primary health care: A Delphi survey of expert opinion. J Subst Use 2004 Jan;9(2):68-85. [CrossRef]
- Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed J E Health 2009 Apr;15(3):231-240. [CrossRef] [Medline]
- Patrick K, Griswold WG, Raab F, Intille SS. Health and the mobile phone. Am J Prev Med 2008 Aug;35(2):177-181 [FREE Full text] [CrossRef] [Medline]
- Riley WT, Rivera DE, Atienza AA, Nilsen W, Allison SM, Mermelstein R. Health behavior models in the age of mobile interventions: are our theories up to the task? Transl Behav Med 2011 Mar;1(1):53-71 [FREE Full text] [CrossRef] [Medline]
- Aitken M. Patient Apps for Improved Healthcare From Novelty to Mainstream. 2013. URL: http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Health%20Institute/Reports/Patient_Apps/IIHI_Patient_Apps_Report.pdf [accessed 2014-11-19] [WebCite Cache]
- Fox S, Duggan M. Pew Internet Project. 2012. Mobile health 2012 URL: http://www.pewinternet.org/files/old-media//Files/Reports/2012/PIP_MobileHealth2012_FINAL.pdf [accessed 2014-11-19] [WebCite Cache]
- research2guidance. 2013. Mobile Health Market Report 2013-2017 URL: http://www.research2guidance.com/shop/index.php/downloadable/download/sample/sample_id/262/ [accessed 2014-11-19] [WebCite Cache]
- Our Mobile Planet - Smartphone penetration 18-24 and 55+. URL: http://bit.ly/1zU0iMR [accessed 2015-01-27] [WebCite Cache]
- Bastawrous A, Armstrong MJ. Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature. J R Soc Med 2013 Apr;106(4):130-142. [CrossRef] [Medline]
- Abroms LC, Lee WJ, Bontemps-Jones J, Ramani R, Mellerson J. A content analysis of popular smartphone apps for smoking cessation. Am J Prev Med 2013 Dec;45(6):732-736 [FREE Full text] [CrossRef] [Medline]
- Azar KMJ, Lesser LI, Laing BY, Stephens J, Aurora MS, Burke LE, et al. Mobile applications for weight management: theory-based content analysis. Am J Prev Med 2013 Nov;45(5):583-589. [CrossRef] [Medline]
- Breton ER, Fuemmeler BF, Abroms LC. Weight loss-there is an app for that! But does it adhere to evidence-informed practices? Transl Behav Med 2011 Dec;1(4):523-529 [FREE Full text] [CrossRef] [Medline]
- Pagoto S, Schneider K, Jojic M, DeBiasse M, Mann D. Evidence-based strategies in weight-loss mobile apps. Am J Prev Med 2013 Nov;45(5):576-582. [CrossRef] [Medline]
- Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. Features of mobile diabetes applications: review of the literature and analysis of current applications compared against evidence-based guidelines. J Med Internet Res 2011;13(3):e65 [FREE Full text] [CrossRef] [Medline]
- Cowan LT, Van Wagenen SA, Brown BA, Hedin RJ, Seino-Stephan Y, Hall PC, et al. Apps of steel: are exercise apps providing consumers with realistic expectations?: a content analysis of exercise apps for presence of behavior change theory. Health Educ Behav 2013 Apr;40(2):133-139. [CrossRef] [Medline]
- Schoffman DE, Turner-McGrievy G, Jones SJ, Wilcox S. Mobile apps for pediatric obesity prevention and treatment, healthy eating, and physical activity promotion: just fun and games? Transl Behav Med 2013 Sep;3(3):320-325 [FREE Full text] [CrossRef] [Medline]
- Mobasheri MH, Johnston M, King D, Leff D, Thiruchelvam P, Darzi A. Smartphone breast applications - what's the evidence? Breast 2014 Oct;23(5):683-689. [CrossRef] [Medline]
- Wolf JA, Moreau JF, Akilov O, Patton T, English JC, Ho J, et al. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol 2013 Apr;149(4):422-426 [FREE Full text] [CrossRef] [Medline]
- Evenstad L. ehealth Insid. NHS England moves to regulate apps URL: http://www.ehi.co.uk/news/ehi/9016/nhs-england-moves-to-regulate-apps [accessed 2014-11-19] [WebCite Cache]
- FDA. Mobile Medical Applications. Draft Guidance for Industry and Food and Drug Administration Staff URL: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/MobileMedicalApplications/ucm255978.htm [accessed 2014-08-30] [WebCite Cache]
- Weaver ER, Horyniak DR, Jenkinson R, Dietze P, Lim MS. "Let's get Wasted!" and Other Apps: Characteristics, Acceptability, and Use of Alcohol-Related Smartphone Applications. JMIR Mhealth Uhealth 2013;1(1):e9 [FREE Full text] [CrossRef] [Medline]
- Cohn AM, Hunter-Reel D, Hagman BT, Mitchell J. Promoting behavior change from alcohol use through mobile technology: the future of ecological momentary assessment. Alcohol Clin Exp Res 2011 Dec;35(12):2209-2215 [FREE Full text] [CrossRef] [Medline]
- Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013 Aug;46(1):81-95. [CrossRef] [Medline]
- Michie S, Abraham C, Eccles MP, Francis JJ, Hardeman W, Johnston M. Strengthening evaluation and implementation by specifying components of behaviour change interventions: a study protocol. Implement Sci 2011;6:10 [FREE Full text] [CrossRef] [Medline]
- Michie S, Johnston M. Behavior change techniques. In: Gellman M, editor. Encyclopedia of Behavioral Medicine. New York, NY: Springer-Verlag; 2011.
- Michie S, Whittington C, Hamoudi Z, Zarnani F, Tober G, West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction 2012 Aug;107(8):1431-1440. [CrossRef] [Medline]
- Direito A, Dale LP, Shields E, Dobson R, Whittaker R, Maddison R. Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques? BMC Public Health 2014;14:646 [FREE Full text] [CrossRef] [Medline]
- Conroy DE, Yang CH, Maher JP. Behavior change techniques in top-ranked mobile apps for physical activity. Am J Prev Med 2014 Jun;46(6):649-652. [CrossRef] [Medline]
- Comstock J. mobihealthnews. One third of docs recommended a health app to patients URL: http://mobihealthnews.com/33594/survey-one-third-of-docs-recommended-a-health-app-to-patients/ [accessed 2014-11-19] [WebCite Cache]
- The Value of Google Result Positioning. 2013. Chitika URL: http://chitika.com/google-positioning-value [accessed 2014-11-19] [WebCite Cache]
- Flurry Insights. The History of App Pricing, And Why Most Apps Are Free URL: http://www.flurry.com/bid/99013/The-History-of-App-Pricing-And-Why-Most-Apps-Are-Free [accessed 2014-11-19] [WebCite Cache]
- Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977 Mar;33(1):159-174. [Medline]
- Abraham C, Wood CE, Johnston M, Francis J, Hardeman W, Richardson M. Reliability of identification of behavior change techniques (BCTs) defined by the "BCT Taxonomy version 1" (BCTTv1) in intervention descriptions. Annals of Behavioral Medicine 2015:- (forthcoming).
- Miller E. evanmiller. How Not To Sort By Average Rating URL: http://www.evanmiller.org/how-not-to-sort-by-average-rating.html [accessed 2014-11-19] [WebCite Cache]
- reddit’s new comment sorting system. URL: http://www.redditblog.com/2009/10/reddits-new-comment-sorting-system.html [accessed 2014-11-19] [WebCite Cache]
- Yelp Official Blog: The Most Romantic City on Yelp is.... Yelp. 2011. URL: http://officialblog.yelp.com/2011/02/the-most-romantic-city-on-yelp-is.html [accessed 2014-11-19] [WebCite Cache]
- Byrt T, Bishop J, Carlin JB. Bias, prevalence and kappa. J Clin Epidemiol 1993 May;46(5):423-429. [Medline]
- Albarracín D, Gillette JC, Earl AN, Glasman LR, Durantini MR, Ho MH. A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychol Bull 2005 Nov;131(6):856-897 [FREE Full text] [CrossRef] [Medline]
- Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008;337:a1655 [FREE Full text] [Medline]
- Carver CS, Scheier MF. Control theory: a useful conceptual framework for personality-social, clinical, and health psychology. Psychol Bull 1982 Jul;92(1):111-135. [Medline]
- Dombrowski SU, Sniehotta FF, Avenell A, Johnston M, MacLennan G, Araújo-Soares V. Identifying active ingredients in complex behavioural interventions for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities: a systematic review. Health Psychology Review 2012 Mar;6(1):7-32. [CrossRef]
- Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:CD000259. [CrossRef] [Medline]
- Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol 2009 Nov;28(6):690-701. [CrossRef] [Medline]
- Higgins ET. Making a good decision: value from fit. Am Psychol 2000 Nov;55(11):1217-1230. [Medline]
- Wright PM, Kacmar KM. Goal specificity as a determinant of goal commitment and goal change. Organizational Behavior and Human Decision Processes 1994;59:242-260.
- Michie S, Jochelson K, Markham WA, Bridle C. Low-income groups and behaviour change interventions: a review of intervention content, effectiveness and theoretical frameworks. J Epidemiol Community Health 2009 Aug;63(8):610-622. [CrossRef] [Medline]
- Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]
- Neighbors C, Larimer ME, Lewis MA. Targeting misperceptions of descriptive drinking norms: efficacy of a computer-delivered personalized normative feedback intervention. J Consult Clin Psychol 2004 Jun;72(3):434-447. [CrossRef] [Medline]
- Doumas DM, Hannah E. Preventing high-risk drinking in youth in the workplace: a web-based normative feedback program. J Subst Abuse Treat 2008 Apr;34(3):263-271. [CrossRef] [Medline]
- Linke S, McCambridge J, Khadjesari Z, Wallace P, Murray E. Development of a psychologically enhanced interactive online intervention for hazardous drinking. Alcohol Alcohol 2008;43(6):669-674 [FREE Full text] [CrossRef] [Medline]
- Hassenzahl M, Tractinsky N. User experience - a research agenda. Behaviour & Information Technology 2006 Mar;25(2):91-97. [CrossRef]
- Voils CI, King HA, Maciejewski ML, Allen KD, Yancy WS, Shaffer JA. Approaches for informing optimal dose of behavioral interventions. Ann Behav Med 2014 Dec;48(3):392-401. [CrossRef] [Medline]
- Rodrigues F, Lorencatto F. University College London. Translating Evidence into Practice : Behavioural Support for Smoking Cessation. University College London; 2013.
- Eysenbach G. The law of attrition. J Med Internet Res 2005;7(1):e11 [FREE Full text] [CrossRef] [Medline]
|BAC: blood alcohol content|
|BCT: behavior change technique|
|PABAK: prevalance and bias adjusted kappa|
Edited by G Eysenbach; submitted 20.11.14; peer-reviewed by D Conroy, L Le Garjean; comments to author 17.12.14; revised version received 28.01.15; accepted 03.02.15; published 14.05.15
©David Crane, Claire Garnett, James Brown, Robert West, Susan Michie. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 14.05.2015.
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