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      A Guided Online and Mobile Self-Help Program for Individuals With Eating Disorders: An Iterative Engagement and Usability Study

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          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.


          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.


          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.


          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.


          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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          Most cited references 31

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          Social learning theory

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            Dropout from Internet-based treatment for psychological disorders.

            The purpose of this review was to present an in-depth analysis of literature identifying the extent of dropout from Internet-based treatment programmes for psychological disorders, and literature exploring the variables associated with dropout from such programmes. A comprehensive literature search was conducted on PSYCHINFO and PUBMED with the keywords: dropouts, drop out, dropout, dropping out, attrition, premature termination, termination, non-compliance, treatment, intervention, and program, each in combination with the key words Internet and web. A total of 19 studies published between 1990 and April 2009 and focusing on dropout from Internet-based treatment programmes involving minimal therapist contact were identified and included in the review. Dropout ranged from 2 to 83% and a weighted average of 31% of the participants dropped out of treatment. A range of variables have been examined for their association with dropout from Internet-based treatment programmes for psychological disorders. Despite the numerous variables explored, evidence on any specific variables that may make an individual more likely to drop out of Internet-based treatment is currently limited. This review highlights the need for more rigorous and theoretically guided research exploring the variables associated with dropping out of Internet-based treatment for psychological disorders.
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              The SCOFF questionnaire: assessment of a new screening tool for eating disorders.


                Author and article information

                J Med Internet Res
                J. Med. Internet Res
                Journal of Medical Internet Research
                JMIR Publications Inc. (Toronto, Canada )
                January 2016
                11 January 2016
                : 18
                : 1
                1Ferdinand Porsche Distance Learning University of Applied Sciences ViennaAustria
                2Ludwig Boltzmann Institut Health Promotion Research ViennaAustria
                3Department of Psychiatry and Behavioral Sciences School of Medicine Stanford University Stanford, CAUnited States
                4Health Promotion Fund Austria, Austrian Public Health Institute ViennaAustria
                5Lantern San Francisco, CAUnited States
                6Department of Psychiatry School of Medicine Washington University St. Louis, MOUnited States
                7mHealth Institute Palo Alto University Palo Alto, CAUnited States
                Author notes
                Corresponding Author: Martina Nitsch martina.nitsch@
                ©Martina Nitsch, Christina N Dimopoulos, Edith Flaschberger, Kristina Saffran, Jenna F Kruger, Lindsay Garlock, Denise E Wilfley, Craig B Taylor, Megan Jones. Originally published in the Journal of Medical Internet Research (, 11.01.2016.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.

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