iEngage©, a health education and behaviour change program integrating a digital app and activity tracker, guided adolescents’ engagement and progression toward higher PA goals and achievements. Adolescents almost doubled steps goals during the program however girls progressed their PA goals slower than boys. They self-reported achieving goals and completing mission over the program at rates above 75% with no difference between boys and girls.
The 5-week program led to increased daily PA (+ 30% or + 2647 steps/day) in both boys and girls, and consistency in achieving 11,000 daily steps increased from 35–48% during the program, boys achieving higher consistency (58%). Accelerometry data collected pre and post the implementation of the iEngage© program indicate that adolescents increased MVPA in daily life through short bouts of activity during recess, lunch and after school.
iEngage, goal settings and achievements
This study is the first to report on the implementation and outcomes of a fully integrated mobile health program in primary school context, using both data self-reported by participants and continuous monitoring of PA during the program. iEngage© was based on BCTs, the Australian physical literacy framework and WHO recommendations for in adolescents18,20,30. In addition, it encouraged connections with friends, siblings and parents through the accomplishment of missions, aiming to endorse the program beyond the school context, as recommended in the literature12,13.
While multicomponent school interventions address key determinants of PA, they are also complex, often resulting in poor implementation fidelity and low effectiveness31. Digital technologies provide the combined opportunity to enhance fidelity for program deployment, to record and evaluate process and to track engagement during the program31. iEngage© takes the full advantage of digital technology through continuous recording of PA behaviour for 5 weeks and capturing all students’ interaction with the platform.
Recent systematic reviews and meta-analysis found interventions using diverse degree of mobile health technologies targeting the promotion of healthy behaviours in schools, however none used mobile health14,32. None of the identified primary studies integrated activity trackers in an educational program and none were set to provide continuous recording and self-monitoring of PA during the intervention. While commercial PA apps exist and may provide an option, a study showed that only a few are suitable for children and adolescents16. In addition, these apps have a limited use of BCTs, provide poor information quality and do not take advantage of scientific evidence16. In addition, mobile apps alone or activity trackers alone do not seem to achieve change of health-related behaviour24,33. Furthermore, studies showed that if students are not appropriately supported when provided with commercial activity trackers and apps, they may feel guilt and internal pressure particularly if a feeling of competition is developed or encouraged24. More recently new evidence-based digital apps designed for adolescents integrated functionalities including self-monitoring of health behaviours but did not integrate activity trackers, experiential learning and self-assessment34. By contrast, iEngage© successfully promoted user engagement via several techniques and features including health and PA education, digital literacy uplift, self-paced goal settings, regular self-assessment of PA achievements against goals, an inclusive design, and missions that aimed to connect the program with the family as previously recommended18. These features and activities were supported through activity tracker data embedded in a structured framework using consistent wordings and graphics, allowing all participants to keep up with the process and to focus on learning and progressing their PA levels. iEngage© promoted achievement of own goals rather than competing for highest PA levels. We found a good concordance between self-reported steps achievements and objective steps/day levels during the intervention, as well as sustained positive feedback indicating a high level of engagement with the program and the app16. This is important since self-efficacy, autonomy in goals-setting and self-assessment as well as intrinsic motivation, which are core to iEngage©, predict the development of PA in young adolescents35. It is known that PA behaviour varies between school days and weekend days particularly in less active adolescents36. Continuous recording and analysis of daily steps over the duration of the program shows that daily PA behaviour did not change linearly and that continuous monitoring during intervention is key to understand patterns. Our study shows that the impact of the program on PA behaviour was stronger during school days compared to weekends, with sharp drop in daily steps over each weekend captured in the study. The effectiveness of a module delivered on Fridays was probably dampened by the change in environment and opportunities during the following weekend days. This suggests that future programs will need to include modules specifically targeting weekends with objectives and goals better adapted to family activities while aiming for maintaining a minimal acceptable level of PA.
Impact of iEngage on MVPA
MVPA can only be assessed through research grade accelerometers which do not provide information to the user on their PA. This was done before and after the program in the iEngage group and before and after a 5-week period in the control group over the same weeks of the school term. At baseline, daily MVPA in all participants was on average ~ 50 min /day with higher MVPA engagement in boys (~ 63 min) compared to girls (~ 43 min), and only 32% of the cohort achieving 60-min/day MVPA on average30. Our data compare well with previous studies using activity trackers in similar age groups: average daily MVPA has been reported to be around 50 min, with more MVPA time in boys compared to girls in Australia37,38 or in the UK where the school system is comparable36.
When analysing post- versus pre-intervention PA, previous systematic reviews and meta-analysis found no or little effect of school-based interventions, with no significant differences between those using or not web-based technology14,31. Our study shows small changes, however, comparable to those obtained after much longer multicomponent school programs31, indicating that our approach and a shorter program was effective. Analysis of hourly MVPA patterns indicated that 48% of the daily MVPA was achieved before the start of class, during lunch break, at recess and just after school (respectively contributing 15%, 10%, 11% and 11% of daily MVPA). On average school hours are more active and less sedentary than the rest of the day. Our results also showed that adolescents increased MVPA during lunch time and recess (+ 40% MVPA, + 4 min) despite the relatively short duration of these periods, indicating that school time provides opportunities30 for MVPA. Overall, our results demonstrate that, after completing iEngage, adolescents were able to effectively identify opportunities for MVPA and that they built up MVPA levels in daily life via short bouts of activities. This may be a direct impact of the program during adolescents were encouraged to identify and take the opportunity of times of the day to be more active, particularly with friends and siblings.
One study37 found that MVPA was the most important activity behaviour for body composition in 11-12-years old and that conversion of sedentary time or light PA time was effective to prevent fat gain pointing to the importance of focusing on MVPA, rather than light PA or sedentary time, for intervention in children and adolescents. The authors found that participants doing on average 23-min MVPA daily, the re-allocation of 30 min daily to MVPA from sedentary time was key to influence body composition. Our results, as well as those from others indicate that interventions with higher initial MVPA lead to an increase in MVPA in the range of 5 to 10 minutes. Shifting toward more MVPA, even in small amounts after school may have significant health impact since it has been shown that sedentary after school time was often associated with recreational screen time and consumption of unhealthy foods39. Importantly, avoiding a decrease in MVPA must also be an important target37. Our results indicate that participants in the control group decreased their MVPA during the same 5-week period (and same period of the calendar year), reinforcing the outcome of the iEngage© program.
Adolescent boys and girls differed from each other with regards to both PA levels and the way they responded to the program. While all students developed competences in setting goals, girls tended to be less ambitious with setting daily step goals during the whole program, progressing goals slightly slower than boys on average. This indicates that, although they were exposed to the same program, the pace at which girls were willing to progress was slower than for the boys. This attitude toward goals setting cannot be explained by physical capacity since girls in the program had similar or slightly better performance across all baseline fitness tests. However, we cannot exclude the impact of perceived fitness or to social norms on goal setting40. While girls set goals at lower step levels during the program, they still struggled to achieve their goals after module 8 when the program encouraged participants to progress above 10,000 steps. Our results still show a significant progression of daily steps in girls, but a longer program may be better suited to the way girls wish to engage with PA programs. Other studies have pointed to the fact that there may be less opportunities for girls to further engage in PA afterschool41, but differences between boys and girls with regards to intrinsic motivation or self-efficacy may play a role35.
While both girls and boys increased daily PA, boys were more successful than girls in increasing MVPA following iEngage. The greater enhancement of PA in boys compared to girls aligns with previous studies on school-based PA interventions including either single (PA) or combined (PA and nutrition) components42 and with multicomponent school-based web-based health interventions14. More specifically, a comprehensive intervention tailored to 13-year-old adolescent girls, including sport, lunch time PA and seminars conducted over 12 months failed to increase PA assessed via accelerometry43. While it cannot be excluded that PA changed during the program, it was not possible to show any significant modification after the program43. A meta-analysis of interventions conducted in any setting in girls aged 12–18 years reported small size effects, large heterogeneity and concluded that behaviour change in girl adolescents will likely be challenging but that school intervention may be more effective41.
One limitation of this study is the relatively small cohort however our results were consistent across the two schools. In each school, all year 5 and 6 students were included indicating that a whole class can participate in the program. iEngage© is a short program with 10 modules delivered over 5 weeks. While this allows for strong focus and facilitates sustained motivation, a slower pace may be envisaged to enable progression and maintenance at slower rates, which may be more suitable for female adolescents. This study specifically focused on PA changes during the program and immediately after, however allowing the adolescents to keep the Misfit Ray© activity tracker and to synchronise weekly with the app once the program is completed could encourage sustaining the behaviour over longer periods.