The Challenge Facing App Developers: Engaging Users

Mental health apps can only help if people use them, but engaging users is hard.

Posted Aug 05, 2020

Over the last decade, the number of mental health apps has grown tremendously to well over 10,000 available for download. However, very few of these apps were developed by psychologists or have any data backing up their mental health claims.

On the flip side, the few mental health apps developed by clinical researchers based on science are not usually very “sexy." Researchers often lack sufficient funding and can’t pay the +$100k needed to create and maintain a sleek app.

Even with unlimited funding, it’s really difficult to create an app that people actually want to use. Do you download apps only to stop using them after a week? You are not alone! This is actually quite common — app usage declines significantly after the first two weeks of use. Mental health app developers face an uphill battle to engage users long-term. 

So what do we do? To ensure app usage, experts suggest that the target population of app users must be included in the development process. A user-centered design process considers the end-user at every stage of development and involves lots of real-world testing.

Developers can also use various strategies to encourage more app usage by targeting hedonic (“fun”) and psychological processes. Strategies like rewards, randomly occurring fun facts, or motivational GIFs may increase user enjoyment of the app.

Other strategies such as interactive features, personalization, and customization, increase app relevancy to users thus promoting user investment and agency. Allowing users to track their health and performance data within the app has also been linked to increased app use.

How much do people need to use an app in order to derive benefit? Intuitively, it makes sense that for users to experience any potential mental health benefits, they have to actually use the app. However, the relationship between use and benefit is complicated.

Studies have suggested that it may not be how much you use the app that is important, but rather how you use the app. Several studies found that overall app usage was not linked to improved mental health or well-being outcomes (e.g., Kenny et al., 2019). One study even found that those with more usage had less symptom improvement (Clarke et al., 2009). This will obviously depend upon the type of intervention the app is delivering, among many other factors.

Some experts have suggested that there might be a subset of activities within an app that underlie “clinically meaningful use” (Zhang et al., 2019). Additionally, after a finite period of effective, in-depth use, the intended outcomes may have already been achieved (Alshurafa et al., 2019; Michie et al., 2017). This may explain why one reason many people stop using apps is that they have achieved their goals.

Thus, when researchers evaluate a new app, it may be helpful to go beyond simple app usage and consider other facets of app engagement. Some researchers have examined engagement as a psychological process related to liking and having an interest in the app, as well as connecting app content to daily life. When researchers only consider objective usage rates, they may miss these other important indicators of app engagement.

To illustrate the complexities of measuring app engagement, take an example from my current study testing a new smartphone app for depression and anxiety. In this study, we had a participant – let’s call them Seun — who was active and interested. Seun had been using the app 3-4x/week as prescribed for the first 2 weeks, and then in week 3, they used the app 0 times. However, during week 3, Seun emailed us to tell us about how they practiced shifting negative thoughts at work, and how much they loved the app’s relevance to daily life. Thus, while Seun didn’t use the app during week 3, Seun was clearly still very much engaged.

Engagement with mental health apps is multidimensional and dynamic. Recent research conceptualizes engagement as a state of user-app relationship that ebbs and flows depending on a variety of personal and environmental factors, and subsumes behavioral (usage), cognitive (thinking about the app content), and affective (liking the app) engagement (Nahum-Shani, 2019).

Research on mental health app engagement is still in its infancy. We clearly have a lot to learn before apps can fully realize their potential to alleviate psychological distress and improve well-being.

Ramya Ramadurai contributed to this article. Ramya is a Ph.D. graduate student in clinical psychology at American University.

References

Alshurafa, N., Jain, J., Alharbi, R., Iakovlev, G., Spring, B., & Pfammatter, A. (2018). Is More Always Better? Discovering Incentivized mHealth Intervention Engagement Related to Health Behavior Trends. Proceedings of the ACM on interactive, mobile, wearable and ubiquitous technologies, 2(4), 1-26. https://doi.org/10.1145/3287031

Clarke, G., Kelleher, C., Hornbrook, M., DeBar, L., Dickerson, J., & Gullion, C. (2009). Randomized effectiveness trial of an Internet, pure self-help, cognitive behavioral intervention for depressive symptoms in young adults. Cognitive behaviour therapy, 38(4), 222-234. https://doi.org/10.1080/16506070802675353

Kenny, R., Fitzgerald, A., Segurado, R., & Dooley, B. (2019). Is there an app for that? A cluster randomised controlled trial of a mobile app-based mental health intervention. Health informatics journal, 1460458219884195. Advance online publication. https://doi.org/10.1177/1460458219884195

Michie, S., Yardley, L., West, R., Patrick, K., & Greaves, F. (2017). Developing and Evaluating Digital Interventions to Promote Behavior Change in Health and Health Care: Recommendations Resulting From an International Workshop. Journal of medical Internet research, 19(6), e232. https://doi.org/10.2196/jmir.7126

Nahum-Shani, I (2019, October 28-29) Engagement in Intensive Longitudinal Data Collection [Conference Presentation], Technology in Psychiatry Summit 2019, Boston, MA. https://www.youtube.com/watch?v=ziROuXluz2k&list=PLWolxJyENg7ies08SDoj1ksbggo-tIxXa&index=9

Zhang, R., Nicholas, J., Knapp, A. A., Graham, A. K., Gray, E., Kwasny, M. J., Reddy, M., & Mohr, D. C. (2019). Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: Mixed Methods Study. Journal of medical Internet research, 21(12), e15644. https://doi.org/10.2196/15644