Usage and dose response of a mobile acceptance and commitment therapy App: secondary analysis of the intervention arm of a randomized controlled trial
Open accessAbstract
BACKGROUND: Mobile phone apps offer a promising medium to deliver psychological interventions. A mobile app based on Acceptance and Commitment Therapy (ACT) was developed and studied in a randomized controlled trial (RCT). OBJECTIVE: To study usage metrics of a mobile ACT intervention and dose-response relationship between usage and improvement in psychological flexibility. METHODS: An RCT was conducted to investigate the effectiveness of different lifestyle interventions for overweight people with psychological stress. This paper presents a secondary analysis of the group that received an 8-week mobile ACT intervention. Most of the analyzed 74 participants were female (n=64, 86%). Their median age was 49.6 (interquartile range, IQR 45.4-55.3) years and their mean level of psychological flexibility, measured with the Acceptance and Action Questionnaire II, was 20.4 (95% confidence interval 18.3-22.5). Several usage metrics describing the intensity of use, usage of content, and ways of use were calculated. Linear regression analyses were performed to study the dose-response relationship between usage and the change in psychological flexibility and to identify the usage metrics with strongest association with improvement. Binary logistic regression analyses were further used to assess the role of usage metrics between those who showed improvement in psychological flexibility and those who did not. In addition, associations between usage and baseline participant characteristics were studied. RESULTS: The median number of usage sessions was 21 (IQR 11.8-35), the number of usage days was 15 (IQR 9.0-24), and the number of usage weeks was 7.0 (IQR 4.0-8.0). The participants used the mobile app for a median duration of 4.7 (IQR 3.2-7.2) hours and performed a median of 63 (IQR 46-98) exercises. There was a dose-response relationship between usage and the change in psychological flexibility. The strongest associations with psychological flexibility (results adjusted with gender, age, and baseline psychological variables) were found for lower usage of Self as context related exercises (B=0.22, P=.001) and higher intensity of use, described by the number of usage sessions (B=-0.10, P=.01), usage days (B=-0.17, P=.008), and usage weeks (B=-0.73, P=.02), the number of exercises performed (B=-0.02, P=.03), and the total duration of use (B=-0.30, P=.04). Also, higher usage of Acceptance related exercises (B=-0.18, P=.04) was associated with improvement. Active usage was associated with female gender, older age, and not owning a smart mobile phone before the study. CONCLUSIONS: The results indicated that active usage of a mobile ACT intervention was associated with improved psychological flexibility. Usage metrics describing intensity of use as well as two metrics related to the usage of content were found to be most strongly associated with improvement. TRIAL REGISTRATION: ClinicalTrials.gov NCT01738256; https://clinicaltrials.gov/ct2/show/NCT01738256 (Archived by WebCite at http://www.webcitation.org/6iTePjPLL).
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ACT-based mobile phone applications are shown to be effective in promoting psychological flexibility and reducing smoking intake.
“ACT-based mobile phone applications are shown to be effective in promoting psychological flexibility24 and reducing smoking intake.25”
From Mixed-methods feasibility outcomes for a novel ACT-based video game ‘ACTing Minds’ to support mental health (2024) · cites this paper as [24]
The Results (Mobile Intervention Participants; page unavailable) report a small within-group improvement in psychological flexibility (d=0.2). The Conclusions associate active app use with improvement, but this secondary analysis of the intervention arm does not establish that the app caused it. Citation 24 is attached only to psychological flexibility; the smoking claim has a separate citation. (LLM, conf=0.86)
Experimental — accuracy not yet measuredA total of 6 studies found that higher engagement was seen with adults aged ≥30 years.
“A total of 6 studies found that higher engagement was seen with adults aged ≥30 years [54,57,64,65,69-71].”
From Barriers to and facilitators of user engagement with digital mental health interventions: Systematic review (2021) · cites this paper as [64]
The Results section reports that older participants used the app more actively, supporting the age-related engagement finding. The Methods section gives an eligible age range of 25–60 years, but the paper does not report a comparison at age 30 or establish that engagement was higher specifically among adults aged ≥30 years. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPast research has shown high app engagement can correlate with higher clinical outcomes.
“past research has shown high app engagement can correlate with higher clinical outcomes [55]”
From Technology enabled clinical care (TECC): Protocol for a prospective longitudinal cohort study of smartphone-augmented mental health treatment (2021) · cites this paper as [55]
A related method used in ACT mobile app research has been to test relations between program usage patterns and outcomes, which have found specific exercises predict stronger outcomes and usage over more weeks predicts stronger outcomes.
“A related method used in ACT mobile app research has been to test relations between program usage patterns and outcomes, which in addition to finding specific exercises that predict stronger outcomes (Heffner et al., 2015), have also found that usage of apps over more weeks predicts stronger outcomes (Mattila et al., 2016).”
From Comparing in-the-moment skill coaching effects from tailored versus non-tailored acceptance and commitment therapy mobile apps in a non-clinical sample (2019) · cites this paper as Mattila et al., 2016
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- Authors
- Mattila, E., Lappalainen, R., Välkkynen, P., Sairanen, E., Lappalainen, P., Karhunen, L., Peuhkuri, K., Korpela, R., Kolehmainen, M., & Ermes, M.
- Affiliations
- VTT Technical Research Centre of Finland (FI)
- University of Jyväskylä (FI)
- University of Eastern Finland (FI)
- University of Helsinki (FI)
- Corresponding author
- Mattila, Elina
- ORCID
- Venue
- JMIR mhealth and uhealth
- Publisher
- JMIR Publications Inc.
- Published
- 2016-07-28
- Volume
- 4
- Issue
- 3
- Pages
- e90
- ISSN
- 2291-5222 (ISSN-L)
- PMC
- PMC4981693
- OpenAlex
- W2479243904
- Cited by
- 67
- References
- 45
- Citations by year
- 2026: 2 · 2025: 7 · 2024: 6 · 2023: 4 · 2022: 13 · 2021: 8 · 2020: 10 · 2019: 7 · 2018: 7 · 2017: 3
- FWCI
- 8.71
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JMIR mhealth and uhealth (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UEF eRepo (University of Eastern Finland) (submittedVersion, cc-by)
- Jyväskylä University Digital Archive (University of Jyväskylä) (submittedVersion, cc-by)
- KTH Publication Database DiVA (KTH Royal Institute of Technology) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Työväentutkimus Vuosikirja (submittedVersion)
- Funders
- Tekes (1104/10)
- Suomalainen Lääkäriseura Duodecim
- Valio
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- acceptance and commitment therapy, mobile health apps, psychological flexibility, dose-response relationship, psychological stress, overweight, lifestyle intervention, Acceptance and Action Questionnaire-II, medication adherence, digital psychological interventions
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