Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Oscar Castro; Jacqueline Louise Mair; Alicia Salamanca-Sanabria; Aishah Alattas; Roman Keller; Shenglin Zheng; Ahmad Jabir; Xiaowen Lin; Bea Franziska Frese; Chang Siang Lim; Prabhakaran Santhanam; Rob M van Dam; Josip Car; Jimmy Lee; E Shyong Tai; Elgar Fleisch; Florian von Wangenheim; Lorainne Tudor Car; Falk Müller-Riemenschneider; Tobias Kowatsch

doi:10.3389/fdgth.2023.1039171

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Front Digit Health. 2023 May 10:5:1039171. doi: 10.3389/fdgth.2023.1039171. eCollection 2023.

Authors

Oscar Castro^#¹, Jacqueline Louise Mair^#^{1

2}, Alicia Salamanca-Sanabria^#¹, Aishah Alattas¹, Roman Keller^{1

2}, Shenglin Zheng², Ahmad Jabir³, Xiaowen Lin³, Bea Franziska Frese^{1

4}, Chang Siang Lim¹, Prabhakaran Santhanam⁵, Rob M van Dam^{2

6}, Josip Car^{7

8}, Jimmy Lee^{3

9

10}, E Shyong Tai^{1

2

11}, Elgar Fleisch^{1

4}, Florian von Wangenheim^{1

5}, Lorainne Tudor Car^{3

8}, Falk Müller-Riemenschneider^{1

2

12}, Tobias Kowatsch^{1

5

13

14}

Affiliations

¹ Future Health Technologies, Singapore-ETH Centre, Campus for Research Excellence and Technological Enterprise (CREATE), Singapore, Singapore.
² Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
³ Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore.
⁴ Centre for Digital Health Interventions, Institute of Technology Management, University of St. Gallen, St. Gallen, Switzerland.
⁵ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland.
⁶ Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, George Washington University, Washington DC, DC, United States.
⁷ Centre for Population Health Sciences, LKCMedicine, Nanyang Technological University, Singapore, Singapore.
⁸ Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.
⁹ Research Division, Institute of Mental Health, Singapore, Singapore.
¹⁰ North Region & Department of Psychosis, Institute of Mental Health, Singapore, Singapore.
¹¹ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
¹² Digital Health Center, Berlin Institute of Health, Charite University Medical Centre Berlin, Berlin, Germany.
¹³ Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland.
¹⁴ School of Medicine, University of St. Gallen, St. Gallen, Switzerland.

^# Contributed equally.

Abstract

Background: Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and methods: A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results: Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions: The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Keywords: behaviour change; chatbot; cognitive behavioural therapy; depression; diabetes; health programme; mHealth.

Grants and funding

This project was conducted as part of the Future Health Technologies program, which was established collaboratively between ETH Zurich and the National Research Foundation, Singapore. The research is supported by the National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise program. Open access funding provided by ETH Zurich.