Emerging mobile health (mHealth) technologies such as wearable devices and smartphone applications for activity tracking have generated new opportunities for promoting healthy lifestyles across diverse patient groups. Yet, for these devices to reach their full potential in facilitating positive health behavior changes, it is necessary to consider the perspectives of target populations to inform intervention efforts (Chiauzzi, Rodarte, & DasMahapatra, 2015). How can wearable devices and smartphones support existing evidence-based lifestyle interventions targeting fitness and weight loss among high-risk patient groups such as people with serious mental illness? What insights can individuals with serious mental illness provide to inform the use of wearable devices and smartphones as part of these interventions?

People with serious mental illness, such as schizophrenia spectrum or mood disorders, are more likely to be physically inactive than people from the general population (Daumit et al., 2005). Physical inactivity combined with high prevalence of obesity and unhealthy lifestyle behaviors such as smoking contribute to poor cardiovascular health, increased risk of comorbid medical conditions, and reduced life expectancy in this group (Colton & Manderscheid, 2006; Richardson et al., 2005; Walker, McGee, & Druss, 2015). Lifestyle interventions aimed at promoting physical activity have shown substantial promise for improving cardiovascular health and contributing to weight loss among people with serious mental illness. Two recent randomized controlled trials of the In SHAPE program, which includes weekly meetings with a fitness trainer and a gym membership, showed clinically significant reduction in cardiovascular risk through improved fitness or modest weight loss in about half of participants (Bartels et al., 2013; Bartels et al., 2015). Similarly, the STRIDE and ACHIEVE programs, which both promote physical activity as part of weight loss efforts, have contributed to modest weight loss of 5% or greater in up to 40% of participants (Daumit et al., 2013; Green et al., 2015). Despite the success of these interventions, they are resource intensive, costly to deliver, and require individualized support and coaching towards reaching personalized exercise or weight loss goals.

Wearable activity tracking devices and smartphones may afford important opportunities to increase the scalability, reach, and impact of existing interventions aimed at promoting physical activity for weight loss among people with serious mental illness. Wearable devices and the companion smartphone applications connected with these devices are increasing in popularity, availability, and affordability. These devices offer numerous features that promote greater engagement among users and make being physically active more fun (Patel, Asch, & Volpp, 2015). These include options for personal goal setting, rewards or trophies for achieving milestones, the ability to connect, compete, and interact with peers and give or receive social support through mobile application interfaces, as well as the capacity to track activity and individual performance over time through user friendly graphs (Lyons, Lewis, Mayrsohn, & Rowland, 2014).

Research in the general population has shown that personal activity tracking may be an effective technique for supporting health promotion efforts and targeting cardiovascular risk factors (Burke et al., 2015). Basic devices such as pedometers provide immediate feedback about number of steps walked and research suggests that this information can help raise awareness about activity levels and increase self-efficacy to be more active (Rooney, Smalley, Larson, & Havens, 2003). A systematic review of studies demonstrated that self-monitoring daily step count using pedometers and setting personal activity goals contributed to increased physical activity and weight loss over time (Bravata et al., 2007). Another study found that increasing the number of steps walked each day among sedentary adults was associated with improvements in measures of cardiovascular health (Lee et al., 2013). Among people with serious mental illness, pilot studies have shown that pedometers are a feasible tool for tracking physical activity over short durations of 2 weeks or less (Beebe & Harris, 2012; Kane, Lee, Sereika, & Brar, 2012).

Wearable devices and smartphones represent a significant advancement over existing methods for tracking activity because they combine the benefits of self-monitoring with added features through mobile applications such as goal setting, tracking activity over time, reminders and prompts, and social connection (Patel et al., 2015). Preliminary research on these new devices has highlighted important benefits such as accuracy for measuring physical activity and feasibility for promoting activity among individuals with chronic medical conditions (Bai et al., 2015; Case, Burwick, Volpp, & Patel, 2015; Chiauzzi et al., 2015). Despite these promising findings, the approaches necessary for promoting the adoption and use of wearable activity tracking devices and the perceived utility of these devices among high-risk patient groups has received less attention (Chiauzzi et al., 2015).

Prior studies have emphasized the importance of understanding the needs, interests, and perspectives of vulnerable patient groups in order to successfully introduce new mHealth technologies (Zulman et al., 2015). For example, working closely with community partners and carefully considering the perspectives of the target population emerged as essential steps towards facilitating the implementation and uptake of a novel mHealth activity tracking system within a low-income African American neighborhood (Yingling et al., 2016). For people with serious mental illness, a recent pilot study showed that a sample of inpatients and outpatients were satisfied and felt comfortable using smartphone sensors for characterizing their daily activity patterns over a 1 to 2 week period (Ben-Zeev et al., 2015). In our prior work, we also observed that popular mHealth technologies appeared feasible for tracking physical activity among a community sample of people with serious mental illness (Aschbrenner, Naslund, Barre, et al., 2015; Naslund, Aschbrenner, Barre, & Bartels, 2015). However, it is necessary to obtain more detailed feedback and specific recommendations from individuals with serious mental illness about their experiences using wearable devices and the companion smartphone applications for these devices over longer time periods in order to inform efforts to promote physical activity for weight loss in this high-risk group.

In this study we employed an exploratory mixed methods approach (Creswell, 2013) to expand on our prior work and to better understand how wearable devices and smartphones can be used to support a healthy lifestyle intervention promoting exercise for weight loss among people with serious mental illness and obesity. We were interested in whether participants would sustain long-term use of these devices over a 6-month time period. We collected quantitative usability and satisfaction surveys and conducted qualitative interviews with participants following participation in a 6-month group-based lifestyle intervention. Our objective was to explore participants’ experiences using the wearable activity tracking devices, synching these devices with a smartphone, and using the companion mobile application. We were interested in obtaining feedback in order to inform the design of a future larger clinical trial.

In this exploratory study we found that people with serious mental illness and obesity enrolled in a lifestyle intervention for weight loss enjoyed using Fitbit activity tracking devices and smartphones, and found that these devices were both motivating and useful for reaching daily step goals. Participants agreed that the devices encouraged them to be more physically active, and they were interested in continuing to use the devices in the future. Specifically, participants’ feedback highlights the acceptability and perceived benefits of wearable devices and smartphones for self-monitoring physical activity, facilitating goal-setting, and providing reminders and prompts to reach daily step goals and to get more exercise.

We have previously demonstrated the initial feasibility of using wearable activity tracking devices among people with serious mental illness (Naslund, Aschbrenner, Barre, et al., 2015). The current findings expand on our prior work by emphasizing the acceptability of using commercially available wearable devices and smartphones to support an evidence-based group lifestyle intervention targeting weight loss. Importantly, we also found that use of these devices was sustained over a 6-month period, which further advances the field of wearable mHealth technology research because to date most published studies of wearable devices have been of relatively short duration (Chiauzzi et al., 2015). Our findings are also consistent with studies highlighting the usability of wearable mHealth devices for activity tracking in general patient populations, including middle age and older adults with chronic medical conditions (Grindrod, 2014) and people with chronic obstructive pulmonary disorder (Vooijs et al., 2014).

Participants were open about challenges they may have faced when learning to use new and unfamiliar technology. Five participants, about half of our sample, reported not having any prior experience using smartphones. For these participants learning to use the smartphone and companion mobile application for the Fitbit was more difficult. However, all participants found the Fitbit wearable device easy to use and easy to understand. Recent studies have highlighted the increasing use and availability of mobile devices among people with serious mental illness (Firth et al., 2015), yet there remain many low-income individuals from this high-risk group who do not have access to contemporary smartphones. When implementing lifestyle interventions using smartphones or wearable mHealth technologies, additional careful consideration of the needs of the target population is essential to ensure that even individuals with limited prior knowledge or experience can similarly benefit.

By closely involving participants in the development, evaluation, and implementation of mHealth interventions, it can help to better understand how these emerging technologies can effectively support health promotion efforts and how to support adoption of these devices in real world settings. For example, development of the FOCUS smartphone application for schizophrenia self-management involved extensive usability testing and feedback from participants to inform specific design elements, including the use of larger buttons, less sensitive touchscreen, and larger font, to accommodate the needs of the at-risk target population (Ben-Zeev, Brenner, et al., 2014; Ben-Zeev et al., 2013). In the current study, we found that participants emphasized the need for more detailed training through group tutorials and more description of practical functions on the smartphones, which may have helped them feel more confident navigating the smartphone interface and accessing the companion mobile application for the Fitbit. As we use these findings to inform a future trial, it is clear that modifications to the way we introduce and deliver mHealth technologies are necessary to avoid excluding anyone who may be unfamiliar with using these devices.

Several participants showed interest in many of the different features on the companion mobile application for the Fitbit. As part of the lifestyle intervention, participants were not specifically instructed to use other features on the mobile application, but could choose to if they were interested. We learned that several participants used the mobile application for weight tracking, logging water, and tracking dietary consumption. This interest in different features highlights the potential for multi-component mHealth interventions that could address multiple health behaviors in this patient group. This is especially important given the high rates of other unhealthy behaviors such as smoking and poor diet among people with serious mental illness. Research shows that smokers with serious mental illness enrolled in lifestyle interventions for weight loss often express high interest in quitting smoking as well (Aschbrenner, Brunette, et al., 2015). This suggests that future mHealth interventions for people with serious mental illness could potentially target physical activity, healthy eating, and smoking cessation simultaneously.

This study offers a novel contribution to the rapidly advancing mHealth field because few prior studies have explored the potential for using mHealth technologies for health promotion in people with serious mental illness (Macias et al., 2015; Naslund, Aschbrenner, Marsch, McHugo, & Bartels, 2015). Efforts to promote physical activity in this group are urgently needed given their low cardiorespiratory fitness (Strassnig, Brar, & Ganguli, 2011), high obesity rates (Dickerson et al., 2006), and resulting early mortality gap (Walker et al., 2015). The sequential steps used to refine and evaluate the use of wearable devices and smartphones for activity tracking among people with serious mental illness align closely with recent emphasis at the NIH on adopting an iterative approach to intervention development and evaluation, especially in the context of emerging mHealth technologies for reaching high-risk groups (Marsch, Lord, & Dallery, 2015; Onken et al., 2014; Onken & Shoham, 2015). This Stage Ia study provides strong support for the acceptability and high satisfaction of using popular wearable activity tracking devices such as the Fitbit among people with serious mental illness, and adds to an increasing number of studies demonstrating that mHealth interventions are both feasible and acceptable for targeting this high-risk group (Alvarez-Jimenez et al., 2014; Naslund, Aschbrenner, Marsch, et al., 2015; Naslund, Marsch, McHugo, & Bartels, 2015). Building on this formative work, future research must focus on determining whether use of these devices contributes to improvements in objective health outcome measures, such as increased physical activity, weight loss, or improved cardiorespiratory fitness over time. Establishing the use of wearable activity tracking devices as a practical, feasible, and scalable approach to addressing the needs of the high-risk group of adults with serious mental illness and obesity is a necessary objective of subsequent effectiveness studies.