This project is guided by the technology acceptance model (TAM), which theorizes that an ICT’s acceptability is determined by its perceived ease of use and usefulness [31]. It is thus hypothesized that greater perceived usefulness and ease of use of the MI-Coach: ED app will lead to greater use and engagement with the app, and subsequently, improved treatment outcomes. It is also hypothesized that participants will experience an improvement in their motivation to recover from an ED following use of the app. In addition, the app’s acceptability and feasibility will be examined, as well as the possible impacts of other clinical variables (eg, depression, anxiety, BMI, and ED severity) on motivation to recover.

Ethics approvals were granted by the University of British Columbia Okanagan Campus’ Behavioral Research Ethics Board (H22-02046) on October 4, 2022, and by the Vancouver Coastal Health Research Institute (V22-02046) on October 10, 2023. All eligible participants provided informed consent electronically through the secure web-based platform Qualtrics prior to enrollment, after receiving detailed information about study procedures, potential risks and benefits, data confidentiality, and voluntary participation. Participants were informed of their right to withdraw from the study at any time without penalty. Participant privacy was maintained by storing data on password-protected university servers accessible only to research personnel. All identifying information was stored separately from the study data. Participants received compensation of up to CAD $40 (≈US $28.41) in the form of digital gift cards. Compensation was clearly outlined in the informed consent form and was structured to avoid influencing participation or app use.

The current pilot test evaluation follows a naturalistic pre-post design. A pilot test framework was chosen to assess the initial feasibility and acceptability of the app and to identify any potential issues with the study design and delivery format prior to evaluating the app’s efficacy at a larger scale [32]. The MI-Coach: ED app was designed to improve motivation in women-identifying people waiting for formal ED treatment and will be pilot-tested in the province of British Columbia, Canada. Qualitative and descriptive data were collected to determine the acceptability and feasibility of the MI-Coach: ED app.

MI-Coach is a self-help app created by Resiliens Inc [40] targeting motivation to engage in health behavior change (eg, exercising, smoking cessation, and sleep hygiene), and is widely available on both Apple and Android app stores. Developed in collaboration with a clinical psychologist and MI expert from the University of Queensland (Stan Steindl, PhD), the app features eight modules, consisting of over 35 lessons led by a registered clinical psychologist with accompanying exercises. In addition, the app includes short articles, mood and behavior assessments, mindfulness-based audio tracks, summary screens and analytics, community-based discussion groups, and the ability to communicate directly with a trained mental health professional.

For the purposes of this study, the content of MI-Coach was tailored for an ED population. In line with best practices for developing ED-specific digital interventions [17,30,41], an in-depth review of potentially iatrogenic or triggering content in the existing app was identified. Specifically, content referring to weight loss or health-focused exercise goals was identified, which prior research suggests may inadvertently reinforce disordered eating behaviors [28,30,37,42]. Subsequently, a literature review was conducted to identify MI topics and ED behavior change goals used in previous interventions, such as exploring reasons for and against pursuing treatment, validating the difficulties of addressing ED pathology, and identifying values and goals driving ED recovery efforts [11,17,30,41].

Following approaches outlined in previous research [15], the research team then performed iterative content analyses to remove or reframe any references misaligned with ED recovery principles (eg, shifting from weight-centric to motivation-centered goals that explore the individual’s reasons for seeking treatment, and the inclusion of topics such as ambivalence and identification of goals and values relevant to recovery). The overall structure and MI principles used in the original app were retained given their demonstrated effectiveness within an ED context [8]. Throughout this process, informal stakeholder consultations were conducted with ED-specialized clinicians involved in the project, who verified the appropriateness of the revised app content. All video lessons were subsequently refilmed using the University of British Columbia Okanagan’s recording studio and equipment. The new videos featured a clinical psychologist with ED treatment expertise to reduce discrepancies between the original and adapted app content (eg, clinical expertise and years of training). Examples of the MI-Coach: ED interface are provided in Figure 1.

Once the adaptation of app content was completed, a new section was built into the interface of the existing MI-Coach app by technological partners (Resiliens Inc) to house the adapted content. Several components of the base app (ie, assessments, audio tracks, analytics, discussion groups, and communication with the mental health professional) were removed to reduce the scope of the project and to protect participant confidentiality. The final adapted MI-Coach: ED app consisted of seven modules (Multimedia Appendix 2) targeting motivation to engage in ED recovery behaviors (eg, help-seeking, values exploration, and self-acceptance) covering the following topics sequentially: ambivalence and behavior change, self-acceptance and compassionate motivation, exploring possible behavior change goals, sustain and change talk, commitment language, and relapse prevention.

The primary outcomes that will be evaluated are the overall acceptability and feasibility of the MI-Coach: ED (Multimedia Appendix 3). Feasibility will be assessed through attrition rates throughout the study period, frequency of app use, and module completion. Acceptability will be assessed through qualitative and quantitative feedback from participants through semistructured interviews and self-reports. Additionally, exploratory analyses will be conducted regarding the impacts of the MI-Coach: ED app on motivation and associated clinical characteristics.

Self-reported demographic data, including gender identity, age, level of education, ethnicity, and socioeconomic status were collected using Qualtrics, a web-based and secure data collection platform. Additionally, clinical data (ie, weight and height, history of ED treatment, age of ED onset, presence of cognitive difficulties, sensory deficits, history of traumatic brain injury, other mental health comorbidities, and ED waitlist experiences) was collected. The Sick, Control, One, Fat, and Food questionnaire [43], a brief screener that identifies the presence of common ED symptoms, was used to determine eligibility prior to enrollment. Clinical characteristics (ie, eating pathology, recovery motivation, body dissatisfaction, depression, and anxiety symptoms) were evaluated through several self-report questionnaires administered at baseline and posttest, including the Eating Disorder Examination Questionnaire (EDE-Q) [44], the Readiness and Motivation for Change Questionnaire (RMQ) [45], the Body Shape Questionnaire (BSQ) [46], the Patient Health Questionnaire-9 (PHQ-9) [47], and the 7-item General Anxiety Disorder Scale (GAD-7) [48]. Additionally, technological literacy was evaluated at baseline using the Mobile Device Proficiency Questionnaire [49] and the eHealth Literacy Scale [50].

Quantitative measures of feasibility and acceptability of the MI-Coach: ED app were assessed using an adapted version of the TAM Questionnaire [31] and the user version of the Mobile App Rating Scale (uMARS) [51]. The adapted version of the TAM questionnaire includes changes to each item to better fit the research question and sample characteristics of this study (eg, “Using CHART-MASTER in my job would enable me to accomplish tasks more quickly” was modified to “Using MI-Coach: ED allowed me to access mental health services more quickly”). An optional semistructured interview was conducted with interested participants to assess their experiences with the app and to further evaluate the feasibility and acceptability of MI-Coach: ED.

An overview of participant flow is provided in Figure 2. Participants were recruited between November 2022 and April 2024. Clinicians and administrators working in a range of ED treatment settings (eg, provincial health authorities, nonprofit charities, and private practice clinics) were contacted via email and asked to share the recruitment advertisement with clients on their waitlists. Interested participants were asked to communicate with the study team via email to enroll in the study. Once initial contact was established, a 15-minute telephone screener was conducted by the study team to assess participants’ eligibility for the study and to provide additional details regarding the study. The Sick, Control, One, Fat, and Food questionnaire was used to evaluate the presence of ED symptoms. Once eligibility was established, consent (Multimedia Appendix 4) and baseline measures were collected through Qualtrics, including a demographics questionnaire, the EDE-Q, the RMQ, the PHQ-9, the GAD-7, and the BSQ. Following this, an onboarding session was conducted through a secure videoconferencing platform (ie, Zoom), during which participants were given a demonstration on downloading and using the app and provided their log-in information.

The subsequent pilot-test portion of the study consisted of a four-week period during which participants used the app in a naturalistic way. Following study completion, participants were compensated CAD $10 (≈US $7.10) for each study portion completed (ie, baseline questionnaire package, onboarding session, posttest questionnaire package, and exit interview), receiving up to CAD $40 (≈US $28.41) through the Tango Card rewards platform. To reduce the impact of possible confounds (eg, financial motivation), participants were informed that their compensation would not be impacted by their app use during the pilot test phase and that there are no minimum requirements for app use. Once the pilot test was completed, a second brief consent form (Multimedia Appendix 5) and posttest questionnaires assessing self-reported clinical features (ie, the EDE-Q, RMQ, PHQ-9, GAD-7, and BSQ) and feedback regarding the app (ie, the adapted TAM-Q and uMARS) were completed. Finally, participants were invited to participate in a videoconferencing-based exit interview to provide additional feedback on their experience with the study author. The semistructured interview guide (Multimedia Appendix 6) was used as an outline to standardize the interview process across participants [52].

Prior to analysis, interview audio recordings will be transcribed verbatim by 2 trained research assistants and verified by the primary researcher (AH-A). Qualitative interview transcripts will be analyzed using the NVivo software package (version 12; QSR International), to assess in-depth feedback regarding MI-Coach: ED’s feasibility and acceptability. A thematic content analysis will be conducted to analyze the qualitative responses from the open-ended uMARS questionnaire and semistructured interview data using Braun and Clarke’s [36] framework. A bottom-up theoretical approach was used, in which the analysis was driven by the data generated through the semistructured interviews [36,53].

Additionally, quantitative analyses will be conducted using the R statistical package (version 4.2.0; R Core Team). Descriptive analyses of posttest feedback questionnaires, attrition data, and sessions completed will be used to determine the feasibility and acceptability of the MI-Coach: ED app. Means, SDs, ranges, and percentages will be calculated for all descriptive variables (ie, age, ethnicity, BMI, height, and weight), and total and mean scores will be calculated for app acceptability measures. Overall app use (ie, number of modules completed, days that the app was used, assessments and exercises completed, and logins) will be calculated using in-app data provided by Resiliens Inc.

Finally, tests of clinical significance [54] will be used to evaluate changes in clinical presentation across time points. The following categorizations will be used to identify whether change is clinically significant: reliably improved, in which there is reliable change and the clinical cutoff is no longer met; reliably deteriorated, in which there is a reliable change in the disordered direction and the individual’s score falls within the clinical range; and unchanged, in which neither criteria of the Jacobson-Truax method are met [54,55]. Finally, exploratory growth curve analyses will be used to model individual participants’ change trajectories across the 4-week pilot test period [56].

This study aimed to evaluate the feasibility and acceptability of MI-Coach: ED, an app designed to support motivation for ED recovery among individuals on treatment waitlists. It is anticipated that the intervention will be feasible to implement, with a high rate of participant engagement with the app, and that MI-Coach: ED would be perceived as an acceptable and useful tool for supporting motivation during the waitlist period. Prior research suggests that digital mental health interventions targeting ED populations are generally acceptable and feasible to users, particularly when they incorporate evidence-based therapeutic principles such as MI [15,28]. Additionally, app-based self-help interventions have demonstrated high engagement rates, which MI-Coach: ED was designed to include [23,27]. Furthermore, we anticipate that exploratory analyses will demonstrate preliminary improvements in motivation and ED-related symptoms following app use, given findings that brief MI-based interventions can enhance motivation for change, improve treatment engagement, and reduce ambivalence in ED populations [8,14,16,17]. As motivation is a key predictor of ED treatment outcomes [11], even small gains during the waitlist period could have meaningful clinical implications.

Individuals with EDs face substantial barriers to accessing appropriate care, despite their urgent need for treatment [37,57,58]. Though both MI and app-based interventions have been suggested as ways to support treatment-seeking ED patients, in isolation, these interventions may not adequately address treatment barriers. For example, in-person MI interventions may be inaccessible to individuals in rural and remote locations, and interventions currently delivered through apps have limited evidence to support their efficacy [24]. As such, this study aims to simultaneously address individual and structural treatment barriers by developing and pilot-testing an MI-based app intervention for women on waitlists for ED treatment.

Providing app-based interventions to individuals who are waiting for ED treatment has the potential to improve treatment outcomes and represents a largely barrier-free, positive-approach method of addressing the growing problem of wait times for mental health care. Although this pilot study focuses on a modest sample, existing intervention frameworks and ED-focused digital interventions demonstrate how pilot studies can be used to guide the adaptation and evaluation of novel interventions through large-scale clinical trials [15,20,28]. For example, collecting and implementing end user feedback prior to formal efficacy testing has been suggested to ensure that the final intervention is used by the targeted population [28]. Furthermore, exploratory analyses on motivation and ED-related symptoms will help identify meaningful clinical outcome measures and establish preliminary effect size estimates to guide the design and power calculations for a full-scale randomized controlled trial. Additionally, by collecting demographic and digital literacy data, this study will provide insights into the app’s accessibility across diverse populations and inform potential adaptations to increase inclusivity. Future evaluations will also aim to follow participants into formal psychological treatment to assess the long-term clinical impact of pretreatment MI interventions.

Given that prior research has demonstrated that multimodal recruitment modalities can enhance sample diversity, improve engagement, and ensure the inclusion of individuals with varying levels of symptom severity in digital intervention studies [38], data collected through this pilot study will be particularly valuable in refining future participant engagement strategies. In this regard, feasibility data collected from this study (including recruitment and retention rates, participant engagement with the app, and qualitative user feedback) will directly inform refinements to MI-Coach: ED and recruitment methods for subsequent large-scale efficacy evaluations, ensuring that the intervention is optimally structured for broader implementation. For example, future studies may continue to use a multipronged approach, such as the use of social media campaigns to supplement clinician referrals [38], and partnerships with provincial authorities may be expanded to integrate study recruitment directly into clinical workflows given their success in prior research [59]. As such, this pilot study serves as a crucial step in optimizing MI-Coach: ED for large-scale implementation and has the potential to provide tangible psychological support to its participants while contributing to the reconceptualization of ED service delivery.