# Adolescents’ Engagement With an mHealth Multiple Health Behavior Change Intervention (LIFE4YOUth): Mixed Methods and Qualitative Comparative Analysis

## TL;DR

This study explores why many Swedish high school students did not engage with a mobile health app aimed at changing multiple health behaviors.

## Contribution

The study introduces a novel approach combining mixed methods and qualitative comparative analysis to identify configurations of factors linked to low engagement in mHealth interventions.

## Key findings

- 67% of participants showed low engagement, with 62% of them never interacting beyond receiving weekly SMS.
- Three configurations of low engagement were identified: unmotivated high-needers, motivated low-needers, and dissatisfied needers.
- Positive experiences of being confirmed and encouraged may explain engagement among students with mixed health behaviors.

## Abstract

Behavior change interventions delivered through mobile phones often have low engagement among end users.

This study aimed to explore factors influencing engagement among Swedish high school students with access to LIFE4YOUth, a mobile-based multiple behavior change intervention targeting physical activity, diet, alcohol consumption, and cigarette smoking. Special emphasis was placed on understanding low engagement.

A sequential explanatory mixed methods design was used. Quantitative usage data from 377 students were analyzed to describe engagement patterns. This was followed by qualitative data collection through 3 focus groups and 2 individual interviews (n=20), analyzed using inductive content analysis. Finally, qualitative comparative analysis (QCA) was used to integrate findings and identify configurations of psychosocial and behavioral conditions associated with low engagement. The results from all phases were interpreted and discussed as a whole.

A majority (253/377, 67%) of participants showed low engagement, with 62% (158/253) never interacting with the intervention beyond receiving weekly SMS text messaging. Focus group discussions revealed 3 overarching categories influencing engagement: perceived importance of behavior change, user experiences, and environment of use. In total, 48% (121/253) of the low-engaged participants were represented by 1 of 3 configurations, which described participants’ characteristics as unmotivated high-needers, motivated low-needers, and dissatisfied needers. Robustness tests confirmed the stability of the unmotivated high-needers configuration.

LIFE4YOUth (Linköping University) did not engage high school students with multiple risk behaviors who were content with their lives and did not consider healthy behaviors as very important. However, positive experiences of being both confirmed and encouraged may explain engagement among students engaged in a combination of health-risk and health-promoting behaviors. Future research could explore how tailoring the number of behaviors targeted by mHealth interventions for adolescents might increase engagement and, in turn, behavioral outcomes.