Non-Communicable Diseases (NCDs) such as cardiovascular disease, diabetes, and cancer, and Common Mental Disorders (CMDs) such as depression or anxiety are the leading causes of death and disability worldwide, causing major health, social, and financial burdens. Similar to other regions of the globe, countries in Southeast Asia, such as Singapore, are facing the challenges arising from the increase of NCDs and CMDs, which pose a significant threat to their healthcare systems.

To address this important problem, our team at the Singapore-ETH Centre, aims to develop and evaluate a scalable digital health intervention for the prevention of NCDs and CMDs. Smartphone-delivered and personalized health interventions may be an effective, low-cost, and scalable solution to prevent these conditions. However, prevention-focused health interventions represent a large unmet need and low user engagement has so far limited the general usefulness of many mobile health interventions. MobileCoach, an open-source platform that is based on an automated conversational agent (chatbot) to deliver scalable, interactive, and engaging mobile health interventions, will be used in this project to address this challenge. In addition, we will leverage an innovative engagement approach that combines storytelling, motivational interviewing, cognitive behavioral therapy, progress feedback visualization, gamification, and builds upon leading evidence- and theory-based frameworks in the areas of behavior change to build our intervention, named LvL UP.

LvL UP will target young and middle-aged adults living in Singapore (including vulnerable individuals) to achieve the following outcomes:

• Increased physical activity and healthy eating
• Improved mood and reduced stress
• Reduced risk of developing NCDs and CMDs
• Improved self-reported quality of life

LvL UP’s digital lifestyle coaches are four characters that portray typical Singaporean lifestyles and who are embedded within an overarching storyline to build a working alliance with intervention users (i.e. a shared understanding about treatment goals and tasks). This attachment bond is robustly linked to treatment success. More specifically, coaching strategies will be personalized according to (1) an individual’s preferences in lifestyle behavior and (2) the current stage of change. In doing so, the coaching will be rooted in  psychoeducation, and cognitive behavioral therapy, covering content in the following three areas:

1. Move More: focused on physical activity, exercise, and sedentary behavior
2. Eat Well: focused on nutrient-rich food, disease-preventing diets, and barriers to healthy eating
3. Stress Less: focused on emotional regulation strategies for stress, anxiety, and low mood management

LvL UP will be adapted to the characteristics of the population and the healthcare ecosystem in Singapore. In addition to the digital coaching provided, it will be explored whether adding human support can help to build a therapeutic bond with users and improve adherence to and outcomes of LvL UP.

To carry out this research, we follow the core principles of the multiphase optimization strategy. In the preparation phase, we will conduct literature reviews, interviews and focus group discussions with individuals at high and low risk of developing NCDs and CMDs, experts, health and lifestyle coaches, and (potential) future providers of LvL UP. We will also develop the conceptual model of the intervention and define the optimization criterion to develop a first MobileCoach-based prototype of LvL UP. A feasibility trial will be conducted with adults living in Singapore, without major exclusion criteria for recruitment. Afterwards, the research plan will involve conducting a Micro-Randomized Trial (MRT) to strengthen the core machine learning technologies behind the engagement mechanisms of LvL UP. Finally, a Sequential, Multiple Assignment, Randomized Trial (SMART) will be conducted to inform the implementation of human support in, and evaluate the effectiveness of, LvL UP.

1. Zheng, S., Edney, S.M., Mair, J., Kowatsch, T., Castro, O., Salamanca-Sanabria, A., Müller-Riemenschneider, F. (2023) Holistic mHealth Interventions for the Promotion of Healthy Ageing: Protocol for a Systematic Review, BMJ Open 2023;13:e066662. 10.1136/bmjopen-2022-066662
2. Castro, O., Mair, J., Salamanca-Sanabria, A., Alattas, A., Keller, R., Zheng, S., Jabir, A., Lin, X., Frese, B., Lim, C.S., Santhanam, P., Van Dam, R., Car, J., Lee, J., Tai, E.S., Fleisch, E., von Wangenheim, F., Tudor Car, L., Müller-Riemenschneider, F., Kowatsch, T. (2023) Development of “LvL UP 1.0”, a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders, Frontiers in Public Health, Vol. 5 (2023), 2673-253X, 10.3389/fdgth.2023.1039171
3. Mair, J., Castro, O., Salamanca-Sanabria, A., Frese, B., von Wangenheim, F., Tai, E.S., Kowatsch, T., Müller-Riemenschneider, F. (2023) Exploring the potential of mobile health interventions to address behavioural risk factors for the prevention of noncommunicable diseases in Asian populations: a qualitative study, BMC Public Health 23, 753 (2023),  10.1186/s12889-023-15598-8.
4. Salamanca-Sanabria, A., Jabir, A., Lin, X., Alattas, A., Kocaballi, A.B., Lee, J., Kowatsch, T., Tudor Car, L. (2023) Exploring the Perceptions of mHealth Interventions for the Prevention of Common Mental Disorders in University Students in Singapore: Qualitative Study, Journal of Medical Internet Research (JMIR) 2023; Vol. 25:e44542 10.2196/44542.
5. Zheng, S., Edney, S.M., Goh, C.H., Mair, J., Castro, O., Tai, B.C., Salamanca-Sanabria, A., Kowatsch, T., Van Dam, R., Müller-Riemenschneider, F. (2023) Do holistic mHealth interventions have the potential to promote healthy ageing? A systematic review and meta-analysis, ISBNPA 2023, Uppsala, Sweden.
6. Keller, R., von Wangenheim, F., Mair, J., Kowatsch, T. (2023)  Receptivity to Mobile Health Interventions, In N. Jacobson, T. Kowatsch, & L. A. Marsch (eds.), Digital Therapeutics for Mental Health and Addiction: The State of the Science and Vision for the Future (1st ed.), Elsevier, Academic Press: Cambridge, MA, USA, 65-77, 10.1016/B978-0-323-90045-4.00006-X.
7. Jacobson, N.C., Kowatsch, T., Marsch, L.A. (2023)  Introduction: A vision for the field of digital therapeutics, In N. Jacobson, T. Kowatsch, & L. A. Marsch (eds.), Digital Therapeutics for Mental Health and Addiction: The State of the Science and Vision for the Future (1st ed.), Elsevier, Academic Press: Cambridge, MA, USA, 1-4, 10.1016/B978-0-323-90045-4.00008-3.
8. Keller, O., Budney, A., Struble, C.A., Teepe, G. (2023)  Blending digital therapeutics within the healthcare system, In N. Jacobson, T. Kowatsch, & L. A. Marsch (eds.), Digital Therapeutics for Mental Health and Addiction: The State of the Science and Vision for the Future (1st ed.), Elsevier, Academic Press: Cambridge, MA, USA, 45-64, 10.1016/B978-0-323-90045-4.00016-2.
9. Kowatsch, T. (2023) How to Lower Socioeconomic Inequalities in Health with Digital Therapeutics? Healthification – A Short Animation, Presented at the Workshop on Best Practices for Scaling-Up Digital Innovations in Healthcare – Scale-IT-up 2023, co-located with the 16th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2023), 16-18 February 2023, Lisbon, Portugal. [PDF]
10. Jacobson, N.C., Kowatsch, T., Marsch, L.A. (2023), Digital Therapeutics for Mental Health and Addiction: The State of the Science and Vision for the Future, (1st ed.), Elsevier, Academic Press: Cambridge, MA, USA, 10.1016/C2020-0-02801-X.
11. Keller, O., Budney, A., Struble, C.A., Teepe, G. (2023) Blending Digital Therapeutics within the Healthcare System, In N. Jacobson, T. Kowatsch, & L. A. Marsch (eds.), Digital Therapeutics for Mental Health and Addiction: The State of the Science and Vision for the Future (1st ed.), Elsevier, Academic Press: Cambridge, MA, USA, 978-0-323-90045-4.
12. Dhinagaran, D.A., Martinengo, L., Ho, M.H.R., Joty, S.R., Kowatsch, T., Atun, R., Tudor Car, L. (2022) Designing, Developing, Evaluating, and Implementing a Smartphone-Delivered, Rule-Based Conversational Agent (DISCOVER): Development of a Conceptual Framework, JMIR Mhealth Uhealth 10(10):e38740, 10.2196/38740.
13. Martinengo, L., Jabir, A., Westin, I.W.T.G., Wai Lo, N.Y., Ho, M.H.R., Kowatsch, T., Atun, R., Michie, S., Tudor Car, L. (2022) Conversational Agents in Health Care: Scoping Review of Their Behavior Change Techniques and Underpinning Theory, Journal of Medical Internet Research (JMIR) 24(10):e39243, 10.2196/39243.
14. Salamanca-Sanabria, A., Ollier, J.B., Mair, J., Kowatsch, T. (2022) Feasibility of the Elena Care for COVID-19 Pandemic Lifestyle Care Intervention, Presentation at the 11th Scientific Meeting of the International Society for Research on Internet Interventions (ISRII) Pittsburgh, PA, USA, Sep 18-21, 2022. [PDF]
15. Mair, J., Salamanca-Sanabria, A., Castro, O., Alattas, A., Keller, R., Kowatsch, T. (2022) Feasibility of LvLUP: designing a smartphone-based chatbot-delivered lifestyle behaviour intervention, Poster presented at the 11th Scientific Meeting of the International Society for Research on Internet Interventions (ISRII) Pittsburgh, PA, USA, Sep 18-21, 2022. [PDF]
16. Castro, O., Mair, J., Salamanca-Sanabria, A., Frese, B., Kowatsch, T., Tai, E.S., von Wangenheim, F., Müller-Riemenschneider, F. (2022) Exploring the potential of existing and emerging digital health technologies in tackling non-communicable diseases and mental health conditions: focus group study with a multi-ethnic Asian population, Poster presented at the 11th Scientific Meeting of the International Society for Research on Internet Interventions (ISRII) Pittsburgh, PA, USA, Sep 18-21, 2022. [PDF]
17. Salamanca-Sanabria, A., Jabir, A., Lin, X., Alattas, A., Kowatsch, T. (2022) Exploring perceptions of smartphone-based interventions for the prevention of common mental disorders with three major Asian populations in Singapore: a qualitative study, Poster presented at the 11th Scientific Meeting of the International Society for Research on Internet Interventions (ISRII) Pittsburgh, PA, USA, Sep 18-21, 2022. [PDF]
18. Kowatsch, T. (2022) Healthification, a short animation about what can we do to lower the socioeconomic inequalities in health, AcademicGIFt No 24, University of St.Gallen, produced by zense, Watch the Short Animation.
19. Salamanca-Sanabria, A., Castro, O., Alattas, A., Teepe, G., Leidenberger, K., Fleisch, E., Tudor Car, L., Müller-Riemenschneider, F., Kowatsch, T. (2022) Top-Funded Companies Offering Digital Health Interventions for the Prevention and Treatment of Depression: A Systematic Market Analysis, Journal of Medical Internet Research Preprints 04/07/2022:40754 preprints.jmir.org/preprint/40754.
20. Jakob, R., Harperink, S., Rudolf, A.M., Fleisch, E., Haug, S., Mair, J., Salamanca-Sanabria, A., Kowatsch, T. (2022) Factors Influencing Adherence to mHealth Apps for Prevention or Management of Non-communicable Disease: A Systematic Review, Journal of Medical Internet Research (JMIR) 24(5):e35371, 10.2196/35371. [PDF]
21. Keller, R., Hartmann, S., Teepe, G., Lohse, K.M., Alattas, A., Tudor Car, L., Müller-Riemenschneider, F., von Wangenheim, F., Mair, J., Kowatsch, T. (2022) Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis, Journal of Medical Internet Research (JMIR) 24(1):e33348 , 10.2196/33348. [PDF]
22. Teepe, G., Da Fonseca, A., Kleim, B., Jacobson, N.C., Salamanca-Sanabria, A., Tudor Car, L., Fleisch, E., Kowatsch, T. (2021) Just-in-Time Adaptive Mechanisms of Popular Mobile Apps for Individuals With Depression: Systematic App Search and Literature Review, Journal of Medical Internet Research (JMIR) 23(9):e29412, 10.2196/29412, Visual Abstract by G. Teepe. [PDF] 
23. Alattas, A., Teepe, G., Leidenberger, K., Fleisch, E., Tudor Car, L., Salamanca-Sanabria, A., Kowatsch, T. (2021) To what scale are conversational agents used by top-funded companies offering digital mental health services for depression? In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) – Volume 5: HEALTHINF, 801-808 (PDF) 
24. Tudor Car, L., Ardhithy Dhinagaran, D., Kyaw, B.M., Kowatsch, T., Joty, S.R., Theng, Y.L., Atun, R. (2020) Conversational Agents in Health Care: A Scoping Review and Conceptual Analysis (2020) Journal of Medical Internet Research, 22(8):e17158, 10.2196/17158. (PDF) 
25. Schachner, T., Keller, R., von Wangenheim, F. (2020) Artificial Intelligence-Based Conversational Agents for Chronic Conditions: Systematic Literature Review, Journal of Medical Internet Research;22(9):e20701, 10.2196/20701. (PDF) 
26. Keller, R., Hartmann, S., Teepe, G., Lohse, K.M., Alattas, A., Tudor Car, L., Müller-Riemenschneider, F., von Wangenheim, F., Mair, J.,* Kowatsch, T*, Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis, Journal of Medical Internet Research (JMIR) 24(1):e33348, 10.2196/33348. 
27. Keller, R., Yao, J., Teepe, G., Hartmann, S., Lohse, K.M., von Wangenheim, F., Müller-Riemenschneider, F., Mair, J., Kowatsch, T. (2021) Are Conversational Agents Used at Scale by Companies Offering Digital Health Services for the Management and Prevention of Diabetes?, In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) – Volume 5: HEALTHINF, 811-816 ISBN: 978-989-758-490-9 ISSN: 2184-4305. [PDF] 

Preprints:  

1. Mair, J. L., Salamanca-Sanabria, A., Frese, B., Jakob, R., Kowatsch, T., & Haug, S. (2023, January 11). Effective behavior change techniques in digital health interventions targeting non-communicable diseases: an umbrella review (Preprint). https://doi.org/10.31219/osf.io/n4sav  
2. Mair, J.L.,* Castro, O.,* Salamanca-Sanabria, A. et al. (2022) Exploring the potential of digital health interventions to address behavioural risk factors for the prevention of non-communicable diseases in Asian populations: A qualitative study, 20 September 2022, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-2068852/v1]    

1. Stieger, M., Flückiger, C., Rüegger, D., Kowatsch, T., Roberts, B.W., Allemand, M. (in press) Changing Personality Traits with the Help of a Digital Personality Change Intervention, Proceedings of the National Academy of Sciences of the United States of America (PNAS). 
2. Shih, I., Tomita, N., Lukic, Y., Hernández, Á., Fleisch, E., Kowatsch, T., Breeze: Smartphone-based Acoustic Real-time Detection of Breathing Phases for a Gamified Biofeedback Breathing Training, Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies (IMWUT) 3(4): Paper 152 10.1145/3369835 
3. Stieger, M., Nißen, M.K., Rüegger, D., Kowatsch, T., Flückiger, C., Allemand, M. (2018) PEACH, a smartphone- and conversational agent-based coaching intervention for intentional personality change: study protocol of a randomized, wait-list controlled trial, BMC Psychology 6(43) 10.1186/s40359-018-0257-9 
4. Kowatsch, T., Volland, D., Shih, I., Rüegger, D., Künzler, F., Barata, F., Filler, A., Büchter, D., Brogle, B., Heldt, K., Gindrat, P., Farpour-Lambert, N., l’Allemand, D. (2017) Design and Evaluation of a Mobile Chat App for the Open Source Behavioral Health Intervention Platform MobileCoach, In: Maedche A., vom Brocke J., Hevner A. (eds) Designing the Digital Transformation. DESRIST 2017. Lecture Notes in Computer Science, vol 10243. Springer: Berlin; Germany, 485-489. (Paper-PDF | Poster-PDF | Slide-PDF | Screencast) 
5. Wahle, F., L. Bollhalder, T. Kowatsch and E. Fleisch (2017) Toward the Design of Evidence-Based Mental Health Information Systems for People With Depression: A Systematic Literature Review and Meta-Analysis. Journal of Medical Internet Research 19 (5), e191. (PDF) 
6. Filler, A., Kowatsch, T., Haug, S., Wahle, F., Staake, T. & Fleisch, E. (2015) MobileCoach: A Novel Open Source Platform for the Design of Evidence-based, Scalable and Low-Cost Behavioral Health Interventions – Overview and Preliminary Evaluation in the Public Health Context. Wireless Telecommunications Symposium 2015 (WTS 2015), New York, USA. ***Outstanding Paper Award & Best Graduate Student Paper Award*** PDF 
7. Stanger, C., Kowatsch, T., Xie, H., Nahum-Shani, I., Lim Liberty, F., Anderson, M., Santhanam, P., Kaden, S., Rosenberg, B. (2021), SweetGoals, a Digital Health Intervention for Young Adults with Type 1 Diabetes: Protocol for a Factorial Randomized Trial, JMIR Research Protocols 10.2196/27109 (forthcoming). 
8. Maritsch, M., Föll, S., Lehmann, V., Bérubé, C., Kraus, M., Feuerriegel, S., Kowatsch, T., Züger, T., Stettler, C., Fleisch, E., Wortmann, F., Towards Wearable-based Hypoglycemia Detection and Warning in Diabetes, CHI 2020 Late Breaking Work, April 25-30, Honolulu, Hawai’i, USA. [PDF] 
9. Lüscher, J., Kowatsch, T., Boateng, G., Santhanam, P., Bodemann, G., Scholz, U., Social Support and Common Dyadic Coping in Couples’ Dyadic Management of Type II Diabetes: Protocol for an Ambulatory Assessment Application, JMIR Res Protoc 2019;8(10):e13685 DOI: 10.2196/13685. [PDF] 
10. Züger, T., Lehmann, V., Kraus, M., Feuerriegel, S., Kowatsch, T., Wortmann, F., Laimer, M., Fleisch, E., Stettler, C., HEADWIND: Design and Evaluation of a Vehicle Hypoglycemia Warning System in Diabetes – A Proof of Principle Study, Poster presented at the Swiss Society of Endocrinology and Diabetology Annual Meeting 2019 (SGED 2019). Nov 14-15, Bern, Switzerland. [PDF]
11. Boateng, G., Santhanam, P., Lüscher, J., Scholz, U., Kowatsch, T., Multimodal Affect Detection among Couples for Diabetes Management, Poster presented at the Black in AI Workshop at the 32nd Annual Conference on Neural Information Processing Systems (NeurIPS), December 7, 2018, Montreal, Canada. [PDF] 

Designing and developing a digital Lifestyle Coach for the Prevention of Non-Communicable Diseases and Common Mental Health Disorders in Singapore

Dr. Jacqueline Mair, Dr. Oscar Castro, M.Sc. Roman Keller, Prabhakaran “Prabhu” Santhanam, Fabian Schneider, Robert Jakob, Prof. Dr. Elgar Fleisch, Prof. Dr. Florian von Wangenheim, Prof. Dr. Tobias Kowatsch 

Prof. Lorainne Tudor Car (NTU), M.Sc. Olivia Clare Keller (ETH & HSG), Prof. Falk Müller-Riemenschneider, MD (NUS), Prof. Dr. Rob Van Dam (NUS), Prof. Dr. E Shyong Tai (NUS)

March 2020 – February 2025