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Mindfulness-based interventions are reported to be highly acceptable and have positive effects on youth, yet most are clinic- or school-based aimed at emotional regulation or academic performance. To provide flexible program delivery, we developed and tested a standalone mindfulness-based app aimed at improving weight-related behaviors (eg, diet, physical activity, sleep) in adolescents.
Our objective was to assess the feasibility, acceptability, and utility of a mindfulness-based mobile app.
In a single-arm pilot study, 15 adolescents (14-18 years) were prompted to access the app once a day, every day for 6 weeks. Outcomes were measured by in-app and poststudy surveys, and descriptive statistical analyses were performed. Time within a mindfulness state was self-reported during weekly timed practices.
The app was rated highly for content and encouraging the practice of activities to promote mindfulness states. Teens reported increased awareness of eating behaviors and high adherence, particularly during physically active practices. Average self-reported time spent in a mindfulness state increased 2.5 times by week 6 (78 [SD 17] seconds) compared to week 1 (31 [SD 21] seconds).
The high acceptability and utility ratings of the app, increases in reported time in mindfulness states, and high frequency of participation, including mindful eating and physical activity, suggest the mindfulness-based mobile app has the potential to improve awareness of weight-related behaviors.
The psychological state of mindfulness facilitates present moment awareness, objective self-observation, and attention to the environment without judgement [
Acceptability of mindfulness interventions in youth is high [
A series of videos was created using animation software (GoAnimate.com) and integrated into an established mobile- and cloud-based app platform developed by our industry partners at Vignet, Inc, thereby creating the b@Ease Mindfulness App. The mobile app and its cloud server are secured and compliant with the Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health Act to protect participant privacy and confidentiality.
Elements of face-to-face mindfulness-based programs were integrated into the videos, including self-observation skill-building, increasing awareness of hunger/satiety cues and the sensory aspects of eating, and purposefully paying attention to physical movement of the body. Regardless of the method used to focus attention (eg, breath), intervention content emphasized achieving and remaining in a mindful state. Videos used fictional storytelling and analogy to communicate, presented techniques to evoke a state of mindfulness, encouraged participation during guided practices, and challenged teens to integrate mindfulness into life as independent practice. Videos range from 2 to 15 minutes (mean 7.5 [SD 2.8] minutes).
Guided practices occurred on 37 days (88% of videos), with mindful eating and physical movement practices presented on 18 days (43% of videos).
Topics:
General mindfulness
Sleep
Mindful eating
Physical activity
Stress
Social/relationships
Techniques to initiate mindfulness states:
Meditation
Guided imagery
Mindful eating
Sensory (eg, auditory, visual)
Body scans (eg, hunger, emotions)
Progressive muscle relaxation
Seated and standing stretching and movement
Yoga and stationary standing postures (eg, balancing)
Mindful walking and martial arts forms
Story examples:
Hippo with insomnia learns breath meditation
Talking body parts argue over who’s really hungry; mindful eating instruction follows
Alien dies from mindless eating accident; how to prevent being a victim with mindful eating
Boyfriend assumes mate is cheating but learns thoughts are not necessarily true; a sensory guided practice follows
Frankenstein’s monster complains about achy body and learns mindful stretching
Boy catastrophizing over a future public speaking event learns mindful walking
Adolescents were recruited from Tucson, Arizona, via flyers posted at community organizations and online (eg, Facebook). Eligibility criteria included teens aged 14 to 18 years willing to participate and use personal mobile devices to use the study app and able to read and speak fluent English. Exclusion criteria included psychological pathologies (depression, anxiety disorders, posttraumatic stress disorder, schizophrenia, bipolar disorder), conditions that affect attention or mood (attention deficit hyperactivity disorder, medications), trauma, epilepsy, and disordered eating behaviors. The Patient Health Questionnaire (PHQ-4) [
At baseline, participants self-reported height, weight, gender, race, and ethnicity. Participants were asked if they had previously heard of mindfulness and whether they had participated in yoga, meditation, guided imagery, body scans, internal martial arts (eg, Ba Gua, Tai Chi), or other mind-body techniques. Participants downloaded the app onto their mobile devices, registered the app, and were asked to access the app every day for 6 weeks. To prevent the study from extending beyond 6 weeks, participants were only able to view one video per day and unable to skip or return to previous videos and the corresponding in-app surveys. Daily prompts encouraged video viewing each morning (streamed from YouTube), and a postvideo in-app survey requested self-reported adherence to video viewing and acceptability (based on a 5-point Likert scale). If the survey remained incomplete by 8 PM, an additional notification was sent. In-app surveys also assessed whether participants engaged in independent practices at least weekly on 8 separate occasions. If the participant indicated they tried the independent practice, a follow-up question asked if it was helpful or enjoyable. The poststudy survey included questions on facilitators and barriers to performing mindful eating and physical activity, likelihood of adopting mindfulness techniques, perceived utility of the content within the app, and app functionality ratings.
Once a week, a scheduled video led participants through a guided timed practice to estimate how long they were able to remain in a mindfulness state. Following the video, participants reported the number of times they were
Acceptability and utility were defined as interest and enjoyment, perceived usefulness, perceived influence on behavior and/or affect, likelihood of adoption of mindfulness techniques, and app functionality. Feasibility was defined as the capacity of the app to engage participants measured by adherence to recommended app use and participant-reported facilitators and barriers to mindful eating and physical activity practices. Data collected within the app included video ratings (based on a 5-point Likert scale) and frequency of adherence to and usefulness of several guided and independent practices (eg, “Did you try it?” and “Did you like it?”) (see
Analyses were conducted using Excel 2010 (Microsoft Corp), Qualtrics survey software (Qualtrics), and SPSS version 23.0 (IBM Corp). Descriptive analyses provided central tendency and dispersion for characteristics of participants, data collected within the app, and from the poststudy survey. Fisher exact test was used to determine whether baseline participant characteristics differed between teens completing the poststudy survey and teens who did not. Statistical significance was defined at the 95% confidence level (
Of the 95 interested respondents, 66 provided their email address to receive a secure link to complete the screening survey. The majority of ineligible participants (43/66, 65%) indicated they may have a mental health condition or received scores on the PHQ-4 suggesting they may have depression or anxiety. A smaller number of teens (12/66, 18%) were ineligible due to scores on the EAT-26 suggesting they were affected by disordered eating behaviors.
Of the 66 participants screened, 20 met eligibility criteria and were enrolled (
All 15 participants provided data within the app including rating videos and answering questions related to independent practices (eg, “Did you try the technique?” and “Did it help you?”), and 9 participants completed the poststudy survey and rated content, techniques, frequency of mindfulness practice, utility of the app to promote mindfulness in various ways, and likelihood of adoption. There were no differences between teens who completed the poststudy survey and teens who did not when comparing gender (
Characteristics of the participants registered for the b@Ease Mindfulness App (n=15).
Variable | User testing | |
Age, years, mean (SD) | 16.5 (1.4) | |
Male | 8 (53) | |
Female | 7 (47) | |
Hispanic/Latino | 9 (60) | |
Not Hispanic/Latino | 6 (40) | |
African American | 1 (7) | |
Asian | 2 (13) | |
Native American | 1 (7) | |
White | 14 (93) | |
Unknown/refuse | 2 (13) | |
BMIb (kg/m2), mean (SD) | 23.1 (4.3) | |
BMI percentile, mean (SD) | 62.1 (26.1) | |
Normalc | 12 (80) | |
Overweight/obesec | 3 (20) | |
Heard of mindfulness, n (%) | 5 (33) | |
Possible prior mind-body practicesd, n (%) | 9 (60) |
aAll applicable races were allowed.
bBMI: body mass index.
cBased upon BMI percentile.
dChoices included yoga (n=7), meditation (n=4), guided imagery (n=0), body scans (n=0), internal martials arts (eg, Chi Gong, n=1), or other mind-body techniques (n=1).
Participants highly rated the videos (in-app survey mean 3.8 [SD 0.3] out of 5). The techniques, guided practices, and the utility of the app were rated highly in the poststudy survey (see
Flow of participants in the b@Ease Mindfulness App for Teens study.
Poststudy survey results of the b@Ease Mindfulness App for Teens study (n=9, all data are mean [SD]).
Using in-app survey responses as a proxy to measure adherence, the percentage of daily responses averaged 55% (all participants) to 73% (excluding 4 teens who stopped participating within the first few days). Thus, participants received an average of 23 (SD 17) days to 31 (SD 15) days of intervention time representing 3 to 4 hours of total viewing. All but one participant reported practicing with real food from some to every time during the guided practices focused on mindful eating; facilitators were timing of video (eg, near mealtime), desire to understand, being told to try it, and feeling appreciation for the body. Participants reported a high frequency of participation during guided physical movement-focused practices, with all but one user participating most to every time. Facilitators included being told to participate (“even though I didn't want to, I did it anyway”), increased positive outcome expectancies, and curiosity. Frequency of independent practice reported within app surveys was moderate with 50% of participants reporting sensory practices and 57% using breath meditation as a means to initiate sleep.
Participants increased their ability to initiate and remain in a mindful state during timed practices over the 6-week study from an average of 31 (SD 21) seconds to 78 (SD 17) seconds. Participation was highest when the duration was 10 minutes or less, and no participant attempted the 15-minute practice.
Mindfulness promotes present moment attention to and observation of the self and environment, which in turn may facilitate self-monitoring of behavior and improve self-regulatory capacities [
The b@Ease Mindfulness App provided 5.5 hours of mindfulness-based content and 3 hours of guided practice time over 42 days. This is similar to face-to-face mindfulness-based pediatric interventions which are often delivered less than an hour weekly for 8 to 12 weeks (8-12 days or 6-9 total hours) [
This study demonstrates the potential for the app to increase mindfulness in teens, but our method of measuring mindfulness has not been validated and is a limitation of the study. However, participant-reported time within a mindfulness state increased over the study (even though practice times also increased), suggesting the app increased the ability of participants to initiate and sustain longer periods of mindfulness states. App survey responses were used as a proxy to measure dose. Videos were streamed from YouTube to reduce file size, and long or repeated buffering reported by a few participants increased the likelihood of the app being closed before surveys were administered. Furthermore, app-generated data indicated high receipt of commands from mobile devices, but these data do not confirm the videos were viewed. We acknowledge the small sample size of this study is a limitation; however, it provides valuable information to allow iterative development of an app involving novel techniques for teaching mindfulness.
A mindfulness-based mobile app, the b@Ease Mindfulness App, was developed and tested for acceptance, utility, and feasibility in 14- to 18-year-old teens. The mobile app successfully delivered videos, which were typically viewed in less than 10 minutes every day for 6 weeks, to participants using an existing app platform. The mindfulness app was rated as an acceptable and useful program by participants, potentially providing greater reach to teens, a demographic who have expressed preference for virtual mindfulness-based health promotion programs [
Surveys sent within the mobile app in the b@Ease Mindfulness App for Teens study.
Poststudy survey questions of the b@Ease Mindfulness App for Teens study.
Examples of comments submitted via the app by teens participating in the b@Ease Mindfulness App for Teens study.
body mass index
Eating Attitudes Test
mobile health
Patient Health Questionnaire
We would like to thank Chris Okawa for his voice-acting talent and help creating the videos and Dave Klein, Praduman Jain, and staff at Vignet Inc for their partnership and support. We also thank Emily Hirshman, Megan Naquin, and Kassie Shaw for their assistance and the study participants for their time and efforts to participate. Funding for this research was made possible by The University of Arizona College of Agriculture and Life Sciences.
None declared.