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. 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] 
2. 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) 
3. 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) 
4. 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) 
5. 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. 
6. 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. Salamanca-Sanabria, A., Castro, O., Alattas, A., Teepe, G., Leidenberger, K., Fleisch, E., Car, L., Mueller-Riemenschneider, F., Kowatsch, T. (2022) Top-Funded Companies Offering Digital Health Interventions for the Prevention and Treatment of Depression: A Systematic Market Analysis (Preprint). 10.2196/preprints.40754  
3. Castro, O.* Mair, J.L.,* Salamanca-Sanabria, A.,* et al. 2022. Development of “LvL UP”, a Smartphone-based, Conversational Agent-delivered Holistic Lifestyle Intervention for the Prevention of Non-communicable Diseases and Common Mental Disorders, OSF Preprints. November 15. doi:10.31219/osf.io/k5cnm. 
4. Salamanca-Sanabria, A.,* Jabir, A.I.,* Xiaowen, L. et al. (2022) Exploring the Role of Mobile Health Interventions for the Prevention of Common Mental Disorders in University Students: A Qualitative Study, November 2022, PREPRINT available at ResearchGate [http://dx.doi.org/10.2196/preprints.44542]  
5. 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]  
6. Zheng, S., Edney, S., Müller‐Riemenschneider, F., Mair, J., Kowatsch, T., Castro, O., Salamanca-Sanabria, A. (2022) Holistic mHealth Interventions for the Promotion of Healthy Ageing: a Systematic Review. PROSPERO 2022 CRD42022315166 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022315166  

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]