A Guided Online and Mobile Self-Help Program for Individuals With Eating Disorders: An Iterative Engagement and Usability Study
Open accessAbstract
BACKGROUND: Numerous digital health interventions have been developed for mental health promotion and intervention, including eating disorders. Efficacy of many interventions has been evaluated, yet knowledge about reasons for dropout and poor adherence is scarce. Most digital health intervention studies lack appropriate research design and methods to investigate individual engagement issues. User engagement and program usability are inextricably linked, making usability studies vital in understanding and improving engagement. OBJECTIVE: The aim of this study was to explore engagement and corresponding usability issues of the Healthy Body Image Program-a guided online intervention for individuals with body image concerns or eating disorders. The secondary aim was to demonstrate the value of usability research in order to investigate engagement. METHODS: We conducted an iterative usability study based on a mixed-methods approach, combining cognitive and semistructured interviews as well as questionnaires, prior to program launch. Two separate rounds of usability studies were completed, testing a total of 9 potential users. Thematic analysis and descriptive statistics were used to analyze the think-aloud tasks, interviews, and questionnaires. RESULTS: Participants were satisfied with the overall usability of the program. The average usability score was 77.5/100 for the first test round and improved to 83.1/100 after applying modifications for the second iteration. The analysis of the qualitative data revealed five central themes: layout, navigation, content, support, and engagement conditions. The first three themes highlight usability aspects of the program, while the latter two highlight engagement issues. An easy-to-use format, clear wording, the nature of guidance, and opportunity for interactivity were important issues related to usability. The coach support, time investment, and severity of users' symptoms, the program's features and effectiveness, trust, anonymity, and affordability were relevant to engagement. CONCLUSIONS: This study identified salient usability and engagement features associated with participant motivation to use the Healthy Body Image Program and ultimately helped improve the program prior to its implementation. This research demonstrates that improvements in usability and engagement can be achieved by testing and adjusting intervention design and content prior to program launch. The results are consistent with related research and reinforce the need for further research to identify usage patterns and effective means for reducing dropout. Digital health research should include usability studies prior to efficacy trials to help create more user-friendly programs that have a higher likelihood of "real-world" adoption.
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This lack of human-centeredness in the development partly explains the high attrition rates and poor engagement often reported in clinical trials and configures a limitation that needs to be addressed to effectively impact survivorship supportive care provision.
“This lack of human-centeredness in the development partly explains the high attrition rates and poor engagement often reported in clinical trials and configures a limitation that needs to be addressed to effectively impact survivorship supportive care provision [39,40].”
From Development and Evaluation of the Usefulness, Usability, and Feasibility of iNNOV Breast Cancer: Mixed Methods Study (2022) · cites this paper as [40]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredEvaluation studies have shown that more severe symptoms hamper actual engagement with digital interventions.
“However, evaluation studies have shown that more severe symptoms hamper actual engagement with digital interventions [51,56,83-101].”
From Barriers to and facilitators of user engagement with digital mental health interventions: Systematic review (2021) · cites this paper as [85]
The Results (Engagement Conditions; no page given) report that symptom severity mattered to participants’ willingness to use the eating-disorder program: some doubted it was suitable for serious eating-disorder issues. But the study reports perceptions during usability testing, not evidence that more severe symptoms reduced actual engagement across digital interventions. The Discussion (Principal Findings; no page given) also notes that greater impairment may increase motivation in some groups. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn 7 studies, participants expressed concerns over the eventual costs associated with using an intervention.
“In 7 studies, participants expressed concerns over the eventual costs associated with using an intervention [85,93,104,123,165,223,224].”
From Barriers to and facilitators of user engagement with digital mental health interventions: Systematic review (2021) · cites this paper as [85]
The Results section (Engagement Conditions; page unavailable) identifies the program’s affordability as relevant to engagement. It does not report participants expressing concern about eventual costs, so the cited study supports the cost-related theme but not the specific concern attributed to its participants. The figure of seven studies belongs to the citing sentence’s group of citations, not to this individual study. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAnonymity could make it more difficult for participants to trust a coach they did not know.
“However, anonymity could also make it more difficult for participants to trust a coach who they did not know [85,127].”
From Barriers to and facilitators of user engagement with digital mental health interventions: Systematic review (2021) · cites this paper as [85]
The Results (Engagement Conditions; page unavailable) say trust was challenging in the online format because participants were initially confused about the remote coach’s nature and role. The same section describes anonymity and privacy as positive factors, but does not say anonymity made the coach harder to trust. (LLM, conf=0.84)
Experimental — accuracy not yet measuredEven if people acknowledged a perceived need for help and were willing to seek help, engagement with a particular intervention was affected by a person's preconceived belief about whether a digital intervention would be effective.
“However, even if people acknowledged a perceived need for help and were willing to seek help, engagement with a particular intervention was then affected by a person’s preconceived belief about whether a digital intervention would be effective [79,104,110-112].”
From Barriers to and facilitators of user engagement with digital mental health interventions: Systematic review (2021) · cites this paper as [110]
The clinical utility of existing apps for people with eating disorders is not clear.
“The clinical utility of the existing apps for people with eating disorders (EDs) is not clear.”
From Cost-effectiveness of the mobile application TCApp combined with face-to-face CBT treatment compared to face-to-face CBT treatment alone for patients with an eating disorder: Study protocol of a multi-centre randomised controlled trial (2018) · cites this paper as [21]
The Introduction (page unavailable) says online eating-disorder programs have shown promising results, while identifying uncertainty about dropout and engagement—not about the clinical utility of existing apps. The Methods and Conclusions (pages unavailable) describe usability testing of one program. Searches for app effectiveness, clinical outcomes, and clinical utility found no passage making the attributed claim. (LLM, conf=0.72)
Experimental — accuracy not yet measured
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- Authors
- Nitsch, M., Dimopoulos, C. N., Flaschberger, E., Saffran, K., Kruger, J. F., Garlock, L., Wilfley, D. E., Taylor, C. B., & Jones, M.
- Affiliations
- Ludwig Boltzmann Institut Health Promotion Research (AT)
- Stanford Medicine (US)
- Washington University in St. Louis (US)
- Palo Alto University (US)
- Corresponding author
- Nitsch, Martina
- ORCID
- Venue
- Journal of Medical Internet Research
- Publisher
- JMIR Publications Inc.
- Published
- 2016-01-11
- Volume
- 18
- Issue
- 1
- Pages
- e7
- ISSN
- 1438-8871 (ISSN-L)
- PMC
- PMC4726867
- OpenAlex
- W2223971542
- Cited by
- 87
- References
- 34
- Citations by year
- 2026: 4 · 2025: 9 · 2024: 17 · 2023: 10 · 2022: 6 · 2021: 11 · 2020: 10 · 2019: 7 · 2018: 10 · 2017: 3
- FWCI
- 10.24
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Journal of Medical Internet Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH100455)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- eating disorders, body image concern, digital health interventions, online self-help program, mobile health, user engagement, usability, dropout, intervention design, think-aloud, user-centered design
- MeSH terms
- Feeding and Eating Disorders, Body Image, Health Promotion, Humans, Interviews as Topic, Motivation, Surveys and Questionnaires, Self Care, Telemedicine, Internet, Mobile Applications
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