In total, 14 participants were approached and 12 (86%) agreed to be interviewed. Participant characteristics are shown in Table 1. Interviewees were similar to trial participants in age, gender, baseline activity, clinical characteristics, and smartphone literacy.
The key themes that emerged from the data were classified into two major interrelated themes:
Transforming relationships with exercise: the ‘Know-Check-Move’ effect
The first major theme that emerged from the qualitative interview data was transforming relationships with exercise. A clear process of change seemed to occur in the relationship between the participant and their exercise behaviour, mediated through their use of the technology; in this case, the app intervention.
After detailed examination, the data revealed clear building blocks, sequentially structured and acting synergistically, which appeared to have the potential to create positive behavioural change around exercise. The current authors termed this novel finding the ‘Know-Check-Move’ effect, which describes how smartphone technology could affect exercise behaviour change. It consists of the following steps that became apparent in the transformational process and are interlinked:
Awareness and knowledge;
Goal setting;
Feedback;
Rewards;
Control and focus;
Confidence; and
Ownership (Figure 1).
Figure 1. The ‘Know-Check-Move’ effect.
Awareness and knowledge
Participants learned how their smartphone, when carried, could monitor their physical activity. They were curious about the number of steps completed during their usual routines and compared these with the recommended daily 10 000-step goal:
‘I never had a method for calculating the number of steps that I did before that, so I was just interested to learn what was my baseline starting off and to just register the number of steps that I did and then I could set targets and just improve my overall fitness.’
(Participant 8)
Participants were often surprised by their own daily step counts. A significant next step for them was to integrate this increased exercise into their lifestyle; as such, the app’s step-counting function served as a ‘teacher’ or tool to instruct the participants as to the actual distance required:
‘OK so once I got over the initial palpitations and had my plan, I tried to get to it and it was a focus and I found that very motivating to have that focus, that I knew now this is actually what you need to have a healthy lifestyle… you need to have this much exercise. I realised what length of a walk was going to get me my steps, you know, and what I needed to do.’
(Participant 11)
Goal setting
Baseline activity levels were ascertained by the participant carrying the smartphone with the application installed but invisible to them. The concept of a daily goal gave participants a focus to work towards while contemplating when, where, and how to achieve it. The technology appeared to make this process more interesting and motivating:
‘I did notice that, what I suspected, was that when I had a goal there I was far more likely to actually get up and do something.’
(Participant 2)
‘I think the goal thing was brilliant for me. Obviously I work better when I am aiming towards something.’
(Participant 3)
Feedback
Those assigned to the intervention group were encouraged to interact with the app, which provided live feedback on daily step count. They were given a physical activity goal of 10 000 steps per day to achieve. Those assigned to the control group were given a physical activity goal of an additional 30 minutes’ walking per day (the equivalent of 10 000 steps), along with their normal activity but did not receive any feedback on their goal attainment.
Participants using the app reported that the instant feedback put them under pressure as they checked it often and it even caused frustration if they didn’t reach the goal:
‘Because you’ve got the instant feedback to see how you get on, so that’s how it was different because it had a focus. It just tuned you in and it got you into the type of the pattern and the routine of having the focus and … well it was much easier to get into a pattern or routine with this focus and getting the feedback, and getting “yes I achieved a target today” or “I’m nearly there”.’
(Participant 11)
Rewards
The extrinsic reward of visualising the step count and comparing it with the 10 000 daily-step goal yielded reports of participants feeling satisfaction and a sense of achievement at their success or, alternatively, feeling frustrated if they didn’t reach their goal:
‘It’s a very easy concept, 10 000 steps a day. It’s easy to remember the phone, is easy to look at your app see how many steps you’re doing, where you are in relation to, like, the graph — you know, whether you’re at zero or near to the 10 000. It’s motivating; you want to get nearer up …you know …to move your little point along the band to get closer to the 10 000.’
(Participant 4)
Participants clearly described the motivation they experienced by using the app:
‘It’s like a “little boss in my pocket”… that’s sort of saying “you know you need to get out and do this”. I don’t know how I’d be if I turned it off. I won’t turn it off, not for the moment anyway. I am quite happy to have it on because I am much more conscious of going out for that walk.’
(Participant 9)
Control and focus
Different achievement strategies demonstrated how the app indirectly encouraged participants to change their exercise behaviour. With barriers such as inclement weather or dark evenings, child minding, and restrictions due to work activities, they developed alternative methods of gaining steps, such as skipping, using a cross-trainer, and walking around the house at night in order to achieve the goal. This highlighted their focus on, and control over, how to accomplish the 10 000 daily steps by timing exercise to suit their individual daily patterns:
‘So it motivated me to find people [babysitters] just for that couple of minutes to get out and do the steps.’
(Participant 4)
‘I tried to make sure that I reached certain little goals in the step count throughout the day. So by 10 o’clock I was used to have been walking a kilometre or 2km into work and by 12 o’clock I was used to having another 2000 steps done …so I tried to set little targets throughout the day so if I was tired by evening time that I’d still have accumulated most of the steps for the day.’
(Participant 8)
Confidence
Participants gained confidence by monitoring feedback on their activity. They began to determine how to plan exercise into their daily routine, such as averaging 2 days’ step count when they were not going to reach their daily target or working towards an overall weekly average:
‘I wanted to get the overall figure of 10 000, irrespective of some days it would have went to 12 000 and some days it would have been 8000. But there was one particular day I was driving all day and the function I was at, there was no walking involved, and then I drove all the way back, so I said that’s going to pull me down on my average.’
(Participant 10)
Ownership
Achieving 10 000 daily steps became a personal goal for participants, an achievement over which they felt ownership. They also reported that being able to use the app independently was an advantage, as was the fact that it was portable and could, therefore, be used anywhere:
‘If I’m going somewhere, number one you bring it with you, number two, you “park away” as I call it, and you walk further, no big deal.’
(Participant 10)
‘But you have control of this yourself. And you can just do it privately and nobody need know anything about it. And you can motivate yourself with yourself and nobody else.’
(Participant 12)
Persuasive technology tools
The second major and interrelated theme was persuasive technology tools, as these were what emerged as the underlying mechanisms of the transformation process in the first main theme. These tools have been previously described in the persuasive technology literature and include:
reduction;
tailoring;
suggestion;
self-monitoring; and
conditioning.20
All of these were evident in the data collected from participants.20 In addition, the proximity of the smartphone was another important factor that was identified.
Reduction
Reduction, or simplifying a task to influence behaviour,20 was evident by the reports that the app was easy to use, required basic numerical literacy, and was highly visible on the home screen. No searching was required unless participants wanted to tap the icon and access the graphs for comparisons with their step-count data from the previous day or week:
‘It was real easy you just put it in your pocket and off you go and… you could do it at your own pace.’
(Participant 5)
Tailoring
Tailoring is providing information specific to an individual in order to elicit a behaviour or attitude change.20 The step count was individual to the participant and served as a motivating factor to increase their walking exercise where possible:
‘I hated going out in the dark but I have gone out as far as the road and back to get my steps and there’s a stepper upstairs and I went on that a few times. Halfway through it, when I became more organised, I decided I know the best time for me to go do this walk is in the morning.’
(Participant 9)
Suggestion
Suggestion describes providing a cue to perform the behaviour at an opportune time.20 The live step-count feedback (Figure 2), which was the centrepoint of a highly visible icon on the app, made participants aware that their steps were being continually tracked, which supported a constant awareness of their goal:
‘I used to make a conscious effort not to check it up ’til lunchtime because I didn’t want to be disappointing myself because I could be standing for long periods when I was (working) and then I’d check it at lunchtime so I’d know in the afternoon I need to make up an extra conscious effort to whizz around the place. Certainly from lunchtime onwards I’d probably check it more and then, last thing, when I was leaving work I’d check it so I’d know exactly what I’d have to do in the evening time.’
(Participant 3)
Figure 2. Live step-count display of the smartphone application.
Self-monitoring
Self-monitoring technology helps people to track their progress to change behaviour to attain a goal.20 Participants experienced various degrees of reported step-count checking behaviour, ranging from every few days, daily, a couple of times per day, and hourly to every time they looked at their phone:
‘I got the app to go out in the front [on the smartphone home screen] so every time I opened the phone I could see the step count.’
(Participant 5)
Conditioning
Conditioning technology uses rewards or positive reinforcements in order to change behaviour.20 The positive reinforcement of seeing feedback on their progress conditioned participants towards the achievement of their goals. Equally, when the participant viewed a low step count, this served as motivation to increase their effort:
‘You’re all day thinking well I haven’t done my 10 000 steps, how can I get another 500 up in the next half an hour or 2 hours before I go home and have to face into coming out and doing another? It was easy to get up in the morning at 6 o’clock that once or twice I did it, and maybe have 7000 or 8000 steps done, and you do 3000 steps throughout the day no problem.’
(Participant 7)
Proximity
Some participants reported that they always have their smartphone in close proximity, while others had to develop the new habit of carrying the phone on them at all times:
‘Very easy because I always have my phone with me anyway.’
(Participant 4)
‘I didn’t carry it on me so it was just to have it on me. When I was working I’d always leave it on the counter and when it would ring I’d come back to it so I just had to remember to put it in my pocket.’
(Participant 5)
Usability
As with any new technology, usability challenges did arise. Some participants required assistance with downloading and setting up the app, while others encountered problems with carrying the phone, resetting the app in the mornings, and increased battery consumption; in some cases this required recharging within a 24-hour period. From a total of 90 trial participants who consented to using SMART MOVE, six discontinued due to excess battery drainage:
‘I got over some of the problems by charging it in the car but, overall, it was frustrating to try and keep it charged all the time.’
(Participant 10)
‘It was very informative. It was worth it, but carrying the phone with me was just… you had to get used to it.’
(Participant 11)
‘Well the app is very straightforward anyway so the only thing I found was I did have to reset it in the mornings.’
(Participant 1)
Features that supported usability were:
The importance of placing the icon on the home screen, where it could always be seen easily and not avoided, was frequently cited:
‘It is set so that when you open your phone it’s on the home screen. So you see without having to go into any app.’
(Participant 12)
Cascade effect
A cascade effect is defined as an unforeseen series of events that can occur due to an action (participant interaction with the app) affecting a particular environment (participants’ wider lifestyle, as well as their family, social circle, and broader community). Discussion of participants’ experiences in the trial appeared to arouse curiosity and encouraged others to become aware of, and monitor, their own physical activity levels:
‘I told my family, I told the people that I was sharing a house with, and there was generally a lot of curiosity about it. I live with two other guys and one of them downloaded an app as well to start monitoring exercise.’
(Participant 8)
In certain cases this went as far as leading to an increase in physical activity levels:
‘You know because Dad, he’d never exercised so he actually got very into this idea of having some regular exercise, of going for a walk because normally his knee would be quite sore. So basically he found he was feeling better, his knee with a little bit more exercise, he was feeling better and he was getting out for it and he decided he’d take the plunge and he bought a cross-trainer.’
(Participant 11)
In addition, using the app to promote physical activity raised awareness of implementing additional positive lifestyle changes for some participants:
‘I think I just said I’d take it as, I suppose, start from day one — try and start as you mean to go on. So I tried to drink more [fluids], I changed from regular tea to decaf, I brought fruit to work so I’d snack on fruit and things like that so, overall, and I’ve continued to do it.’
(Participant 3)
