Healthy Jeart. Developing an app to promote health among young people

1 Healthy Jeart. Developing an app to promote health among young people. Healthy Jeart is a free app targeted to young people. It is especially designed to foster a healthy lifestyle. Young people can find in it practical recommendations about seven areas of health and a game through which they can consolidate the acquired knowledge on different healthy and beneficial elements. Healthy Jeart is also useful for healthcare professionals and educators. The latter can find in it educational proposals in the subject that can be implemented in schools and challenges in which they can get students to participate and compete. Healthy Jeart has been awarded the distinction of Health App by the Andalusian Agency for Health Quality and is supported by the Community Nursing Association (CNA) at the national level. Healthy Jeart is a health promotion tool that was created with a low cost; however, the impact on the physical, psychological and social well-being of young people is expected to be high. The present article describes its design, production, revision and evaluation process. The design of this tool required knowing how young people perceived it and determining the contents that should be included in it. Such information was gathered through eight nominal groups. Once the first prototype was available, this was tested with a sample of adolescent students. With the accreditation procedure, given the attended improvements to pass it, the current version of the application was reached. mobile; gamification; education; health; lifestyle. Introduction The amount of commercial apps available that promote a healthy lifestyle has increased. However, few of them are targeted to children and teenagers. Moreover, these cover objectives and contents that contribute to either the physical, mental or social well-being; however, they do not focus on the whole health state. The same occurs with the prototypes presented by previous studies. Such is the case of those apps that allow people to improve their diet and nutrition (Coughlin et al. 2015). The app created by Wong et al. (2017) contributes to the recognition of the ingredients we find in packed foods, while it also guides the user toward a healthy diet through alerts or suggestions. The gamified app “Snack Track School” shows children how to Manuscript (must not contain author information) Click here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 2 choose healthy snacks, implementing the reward-based learning strategy (Van Lippevelde et al. 2016). O PEGASO Companion is a smartphone app exclusively targeted to fight and prevent overweight and obesity among young people by focusing on motivation and proposing personalised interventions (Caon et al. 2017). Educational experiences based on these apps have proved them to be beneficial. They help obese and overweight people to lose weight and control their gain/loss, and they encourage young people to eat healthier (Šmahel et al. 2018). They improve the physical activity of adolescents (Lee et al. 2019). They also help to reduce the concentrated consumption of alcohol, expanding the recognition of the negative and dangerous consequences of drinking it (Carr et al. 2016). Some of these apps also increase the efficacy of mindfulness interventions (Lucas Thompson et al. 2019). However, young people, as well as adults, have a holistic vision of health. The main objective of the present study was to produce a mobile app that would foster healthy habits among young people to lead them to their physical, psychological and social well-being and help them to consolidate a healthy lifestyle. Adolescence is a stage in which people undergo important physical, cognitive, emotional and social changes. These changes are classified into four large areas: physical/biological development, cognitive development, emotional development and social development. The combination and complexity of these major vital changes is what makes adolescence a key stage for the promotion of healthy life habits. The need to approach primary prevention in young people as a key strategy to improve the impact on public health has been reported by the World Health Organization itself. In the “Health for the world’s adolescents. A second chance in the second decade” report (WHO, 2014), the stage of adolescence is identified as a great opportunity in the second decade (10-19 years of age) to educate people in a healthy lifestyle. This report emphasises that, in this stage, the unhealthy life habits learned during 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 3 childhood can still be corrected, and that the health state at adolescence and early adulthood influences the rest of a person’s life. Therefore, it is necessary to grant them the possibility to acquire and consolidate such knowledge easily and quickly. Furthermore, it is necessary to approach the acquisition and consolidation of healthy habits considering the combination and complexity of the physical, cognitive, emotional and social changes that take place throughout this evolutionary stage. Technology can contribute to the promotion of healthy habits in this sector of the population; however, to this end, technological tools must help them to feel better generally. This must be done through entertaining formulas and using their own communication codes (Carrión et al. 2016). Therefore, gamification plays a predominant role, and interaction among users is favoured in the app created in this study. In addition, the content of the app is based on the needs of the users and it is treated and presented exclusively for them. Problem Statement The lifestyle of young people nowadays can be characterised considering different patterns (Garca Poole, Byrne and Rodrigo 2018). The available data support our objective, as they show that healthy behaviours are not representative of the total of this population. Next, a brief review is presented. The ALADINO 2015 study (Ortega et al. 2016) showed that the prevalence of overweight in children between 6 and 9 years of age was 23.2%, whereas the prevalence of obesity was 18.1%. As factors associated with obesity, certain eating habits were pointed out, such as skipping breakfast every day and the lack of physical activity. According to Sánchez Cruz et al. (2013), in 2012, for the age group of 8 to 17 years, the prevalence of overweight was 26% and that of obesity was 12.6%. Four out of ten young people suffered from overweight, with 45% of minors with ages between 8 and 13 years showing excess weight. In 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 4 this context, it is recommended to extend preventive measures to all teenagers, including those who have a normal body mass index (Martínez Villanueva 2017). In the 2016 report on physical activity in children and adolescents in Spain, the indicator of global physical activity was given a score of D-. This means that less than half of the children and adolescents follow the recommendations and that there is a great difference in the levels of physical activity between boys and girls in all age groups. Among the results of the HBSC-2014 study in Spain (Moreno et al. 2016), it is worth highlighting that only 24.4% of adolescents carried out physical activity seven days per week for at least 60 minutes per day. This frequency of physical activity was clearly higher in boys than in girls. Alcohol is the most extended psychoactive substance among students of secondary education in the range of 14 to 18 years of age. The second most prevalent drug is tobacco. The age at which the consumption of alcohol and tobacco begins, in average, is below 14 years. The period between the first time of use and daily consumption is shorter than one year, which is observed since 2010. The prevalence of acute alcohol intoxications shows some differences regarding the gender and age of students. In the group of 16 years, more than 50% have experienced an intoxication (OEDT 2016). The consumption of cannabis does not take place until the age of 16-17 years, in average. Moreover, the concept of polydrug use is misunderstood. Young people do not associate this with the consumption of alcohol and cannabis or alcohol and tobacco. They consider that polydrug use refers to some stigmatised consumption (Pascual, 2017). The beginning of complete sexual relations takes place at the age of 15-16 years. Among adolescents who have sexual intercourse, 20.9% have used at some point the morning-after pill or another emergency contraceptive (Alfaro Gonzlez et al. 2015). A large percentage of young people agree or totally agree with the assertion that “there are couple 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 5 relationships among young people in which there is violence”, with girls being more convinced than boys about this statement (Eresta, Delpino and Rivas 2013). Background The interest for mobile applications about health has increased, giving rise to the development of tools specifically designed for the analysis of their quality, such as the MARS scale (Stoyanov et al. 2015). Thus, numerous research teams have delved into the tedious task of evaluating these applications (Flaherty et al. 2018). This is the case of Schoeppe et al. (2017), who became interested in apps for young people. With the results of their study, they demonstrated that the general quality was moderate. Their functionality was the aspect with the best valuation, and their quality was the one with the lowest score. According to these authors, the most frequent behaviour change techniques (BCTs) in these apps were ‘Provide instructions’, ‘Provide general encouragement’, ‘Provide contingent rewards’, and ‘Provide feedback on performance’. Up to 93 BCTs, organised in 16 dimensions, constitute the consensual taxonomy of Michie et al. (2013). According to Edwards et al. (2016), these apps include at least five BCTs, with self-regulated BCTs being the most frequently used (feedback and monitoring including self-monitoring of behaviour). Brannon and Cushing (2015), through a systematic literature review, focused on determining which BCTs were most effective at modifying the diet and physical activity exclusively in children and teenagers. Their study revealed that the most important BCTs for children were modelling, practice and social support. On the other hand, the range of BCTs was broader for teenagers, including: consequences for behaviour, information on other’s approval, intention formation strategies, self-monitoring, and the use of a behavioural contract. Likewise, it was concluded that most of the effective strategies for children were not 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 6 widely incorporated in these apps, and that this aspect was better in the case of teenagers. In the review conducted by Dute, Bemelmans and Breda (2016), it was demonstrated that most of the analysed apps for the promotion of healthy nutrition worked as monitoring tools. Therefore, despite the proliferation of this technology, awareness is still low in young people. Moreover, one of the limitations of these apps is the widely shared perception that they are boring (Chan, Kow and Cheng 2017). It has been recently stated that gamification would be an encouragement element (Lee, Lee and Lee 2017). The main purpose of gamification would be to guarantee regular participation and increase the involvement of the users with the app (Sardi, Idri and Fernández Alemán 2017). Marston and Hall (2016) showed examples of possible uses in the prevention of unhealthy habits and the promotion of healthy lifestyles. However, the reality is that few applications incorporate game elements (Edwards et al. 2016). Design and production The design and production process of Healthy Jeart consisted of different phases. This section describes each of them. First phase. Development of nominal groups The design of the Healthy Jeart app began with an exploratory, qualitative and interdisciplinary study. For the gathering of data, the technique of nominal groups was used, whose analysis provided information about the topics that potential users considered that should be tackled in the app. This technique was originally developed by Delbecq and Van de Ven (1971) and was first categorised as nominal group technique (NGT) by Rohrbaugh (1981). It was chosen for being well-suited to the objective of this study. The aim with it was to reach a consensus about decision making in the research team, maintaining a balanced participation among all 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 7 the members, which is more difficult to achieve with other techniques, such as discussion groups or the delphi technique (Olaz 2010). Between the months of March and April, eight discussion groups were created in different public and concerted schools of primary and post-compulsory education in Huelva (Spain), as well as in the University of Huelva. Three groups were constituted by 6th grade students from primary education (26 participants), two groups were made up of secondary education students (28 participants), two groups consisted of baccalaureate students (29 participants) and one group was composed of university students (9 participants). A total sample of 92 students participated in the study, who were recruited following a convenience, non-probability sampling. The written consent of one of the parents or legal guardian from each of the minors was required for their participation. During the process of data gathering in the different discussion groups, there were always two members of the research team in charge of the project; one of them directed and coordinated the session and the other carried out support tasks and wrote down what happened in these sessions and what the participants stated. To ensure that all the discussion groups followed the same dynamics, an action protocol was created. In the design of this protocol, we followed the guidelines recommended by authors such as Abdullah & Islam (2011) and Olaz (2010). This protocol specifies the precise steps and instructions that must be followed. In each of the discussion groups, the sessions always began by providing the participants with information about the project and the purpose of developing the mobile application. Then, they were asked to think about the factors (behaviours, elements, etc.) that they considered to be influencing their health (physical, psychological and social) and that of their closest peers. Based on that, they had to answer, on paper and individually, to the following key question: What habits do you consider to be most interesting to include in the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 8 mobile application about how to improve your physical, psychological and social health? After a time of personal reflection, the next step was an open discussion in which all participants were asked to show the answers they had written. This process was carried out in an ordered manner, by turns, to promote the participation of everyone. Once this stage was completed, they were asked to explain those answers that were not totally clear, to allow the entire group to understand them properly. Lastly, the students voted the five factors that they personally considered to be the most important of all the factors they had mentioned. The information gathered in these nominal groups was subjected to a process of content analysis during the last trimester of the academic year, conducted by the researchers of the project. This analysis allowed grouping the data into different categories and subcategories, from which 7 major content areas to be approached in the application were proposed. Analysis of the content of the nominal groups The analysis of the information gathered in the nominal groups was conducted through a content analysis. The emergent categories and subcategories are presented in Table 1. TABLE 1 Considering that the contents to approach in the app should be related to the emergent categories of the content analysis conducted, the research team of the project renamed these in seven major areas in order to make them more understandable and motivating for the end users. It is important to highlight that three final areas were named as three of the resulting categories of the nominal group analysis: “Physical well-being”, “Psychological well-being” and “Toxic substances and addictions”. A fourth area, “Sex and relationships dimension”, was considered, in order to tackle the contents related to the “Sexual habits” category. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 9 The areas “Physical activity” and “Food” were incorporated to the seven main areas for being the subcategories that were most requested by the nominal groups. Lastly, the area “New technologies” was added for being a transversal subcategory, that is, it was present in all the analysed categories, and due to the fact that it is considered to be of great importance nowadays. Phase 2. Definition of the appearance and preparation of the content The app was designed and developed by an interdisciplinary team of researchers of the Universities of Huelva and Seville (Spain), who had experience in education for health. They assumed the responsibility with the support of the Andalusian Health Council, which funded the initiative, and other entities, such as the Atlantic Copper Foundation, the Official School of Nursing and other university departments that co-funded it. The research team focused on determining the functionality and defining the appearance of the app; they are also in charge of selecting and writing the available content in Healthy Jeart, although this is later revised by experts in this field at the national level to guarantee its suitability and adequacy. Phase 3. Production and pilot test The technical production of the app was delegated to an external entity, which carried out their work under the constant supervision of the research team of the project. The first prototype was tested with a sample of 69 students from different centres of primary and secondary education and baccalaureate of the Huelva province as possible users of the application. The principals of those centres were informed and they authorised the experience. The parents and legal guardians gave their consent and allowed the participants to take their mobile phones with them to school. In the classroom, both the teachers and the students installed the app and interacted with it. Then, the students were asked to complete a questionnaire. In this questionnaire, the participants were asked to value, in a scale of 1 (very bad) to 5 (very good), different aspects of the app (such as its ease of use and the clarity of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 16 ● New technologies: they give ergonomic recommendations, highlighting the risks of the Internet and its inappropriate use, thus they promote a safe and responsible use of ICT, raise awareness about the influence of mobile devices on sleep and other consequences of an excessive or inadequate use, etc. Regarding these brief advices, the users can obtain further information by checking the recommended additional content. The TIPS can be updated by the administrators, thereby the content is dynamic. The game In addition to the TIPS, a simple game allows consolidating the knowledge acquired about healthy habits. The main character of the game is Jeart, a likable heart-shaped alien. In the “Gallery of characters”, the user can modify its appearance before initiating the game, although this cannot be done the first time, since changing the way Jeart looks requires gems. Initially, Jeart looks weak; however, the users will be able to make him more resistant to harmful elements. Jeart must follow a vertical route. In his journey, he must avoid a series of elements that are harmful to his health and get in contact with other elements that are beneficial. Thus, young people learn subliminally to differentiate one from the other. Points are accumulated as Jeart goes up and collects the objects which represent activities and products that are beneficial to health (sports, fruit, vegetables, fish, water, etc.). The points obtained in each game do not add up; unlike gems, which, once obtained, remain in the user’s account. The score may be shared through social networks, thereby WhatsApp and Instagram become means through which the users can compare their achievements and compete. Certain harmful products, such as sugar, snacks and soft drinks, reduce the health bar of Jeart only by touching them. Other elements, such as alcohol, tobacco and drugs, make 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 17 Jeart lose all his health instantly and, consequently, the game is over. At the top of the screen, the user can check the health bar and monitor its variations. Time also contributes to the decrease of health. In his way up, Jeart performs automatic jumps on different thrusting platforms. The most common platform is the one that represents a static island. However, other platforms can move, break, etc., which can be bad for Jeart, who would fall down. Of all the platforms, the white one stands out, as it increases the health bar. These white platforms represent “rest”. Thus, resting is also valued in this game. The user guides Jeart by moving the mobile device slightly, making the internal gyroscope of the latter react. Eventually, the game ends when the health bar of Jeart reaches zero, either due to the effects of harmful elements, the time runs out or because Jeart falls down. In any case, the user has two options: finish the game, share the result and exit, or answer a simple question to keep playing. The game can continue only if the answer is correct. The questions have one possible answer and there is an establish period of time to select the answer and send it. If the time runs out, the game is over. FIGURE 2 Along with the game, the app has a forum where the users can exchange healthy ideas. These must be approved by the administrators, who also evaluate them. The valuation is materialised in stars, which the users can exchange for gems for the game. Gems can also be obtained throughout the course of the game. As was already pointed out, they allow changing Jeart’s avatar. Health challenges 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 18 The aim of the challenges is to make the users acquire or modify certain habits. They refer to activities that must be developed in the classroom. For instance: carrying out a breathing exercise after the break. These activities must be implemented in the educational centre for, at least, 21 days (estimated time to change habits). They must be performed in the presence of the teacher and, in some cases, with the collaboration of the classmates. The teacher is the person who manages the experience, that is, the one who proposes the activities to the students and ensures that these are carried out in time and properly. Moreover, the teacher is the person who must inform the administrators of Healthy Jeart about how these activities are carried out, what results are generated and how they will develop in the future. The experiences are evaluated from the information provided. Of all the centres participating in each challenge, one will be the winner and will be awarded a certification, which will be automatically issued by the app. The archive of learning activities Lastly, a set of didactic activities about healthy habits is at the disposal of teachers and other professionals. The aim is to expand the knowledge of young people about each of the seven areas of health, promote healthy behaviours, develop attitudes that result in healthy habits and favour the transmission of the learnings to their lives, achieving a healthy lifestyle. In order to describe the activities, a common scheme was followed. Each of them provides information related to: ● End users: educational stage and level in which the app can be implemented, and estimated age at which students can participate. ● Objectives and contents: itemization of the educational objectives of the activity, as well as of the contents tackled. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 19 ● Activities: sequence of steps to follow and precise instructions about what must be done and how. The tasks given to the students will respond to different types: assimilative (e.g., visualise the short movie “The cycle of butterflies”), productive (e.g., make a collage that presents the previously calculated amount of sugar of different foods), experiential (e.g., visit a supermarket to analyse ultra-processed foods), etc. The role of both students and teachers will vary depending on the tasks demanded. ● Methodology: general description. Options are given for the adaptation of the activity and precise indications about the type of student grouping required, which, in general, responds to: large group or class group, individual work and small groups. ● Timing and spaces: total length of the activity and infrastructure needed, indicating whether the space required technology. ● Evaluation: proposal for the formative evaluation of the activity. About the software Healthy Jeart is a software in which the following components work jointly with one another: ● Two native applications compatible with iOS and Android devices, through which the users can interact with the contents and participate in the activities and in the game. These apps are in Objective-C and Java languages, respectively. ● A web application which only the administrators can access. From it, the contents of the native application are managed. This backend is in Php-MySQL language. ● An action game developed in Unity, accessible from the native apps. This game is in C# language. FIGURE 3 Results 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 20 The task of disseminating app is intense. Previous experiences in our context indicate that a lack of investment in communication will have a negative impact on the reach of the application (Lazo Caparros 2015). On the one hand, informative spaces were dedicated to it in television channels and local and regional radios. Some websites have presented this app, such as that of PiCuida (Care Network of the Andalusian Care Strategy) and the Andalusian Early Childhood Observatory. The app has also been disseminated through Twitter, by @CalidadAppSalud, for instance. On the other hand, the research team is investing in different forums in the university context and advertising the app in the educational centres of primary and secondary education of the province of Huelva. In support of this effort of information presentation, in parallel with the development of the application, a website was created, which presents the project and the app 1 . Moreover, an advertising video was edited by an external entity and is being shared in social networks and instant messaging systems. In the first twenty days after launch, before its official presentation, the app was already among the most popular in the category of educational apps of Play Store. To be specific, it was number 9 in September of 2018. Healthy Jeart has over 1000 downloads in Play Store. In total, 111 users have given their valuation about it. The average score is 4.9 out of 5. The comments of the users highlight its main characteristics: entertaining, didactic, useful and attractive. “Very useful application for children to learn healthy habits in a novel and entertaining manner”. “It is a fantastic application for learning healthy habits while playing. Very well-suited for children and teenagers. It is innovative, attractive and useful. I recommend it 100%”. 1 https://www.healthyjeart.com/ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 21 In App Store, the app has been valued in a very similar way (4.8 out of 5). According to the daily reports of Fabric (platform used by developers to follow-up mobile applications for both operating systems), in December 2018 there were up to 692 active users. Therefore, to date, the app has been downloaded over 1600 times. Conclusions and future planning Well-designed mobile applications can be very functional tools as part of health promotion strategies (Dute, Bemelmans and Breda 2016). Young people believe so (Carrión et al. 2016). Healthy Jeart is a new available app exclusively designed for them. It promotes healthy habits that respond to different areas of health, and it is not focused on a single area of health, since its purpose is to foster a healthy lifestyle in systemic terms. To this end, Healthy Jeart implements different behaviour change strategies, trascending the application itself (Michie et al. 2013). The app was developed to be used exclusively in educational centres. Specifically, the instructions on how to perform a behaviour, the feedback on that behaviour and the modelling of behaviours are promoted through challenges and activities, which must be implemented in the classroom under the guidance of the teacher. The challenges and activities are also based on the strategy of social support, as their purpose is to stimulate the effect of interactions, collaboration, etc., which take place within groups of peers. The development of habits lies in the tips and in the game. Moreover, the game and the forum implement rewards and incentives. One of the characteristic elements of Healthy Jeart is its game. Aware of the educational value of these for promoting healthier nutrition behaviours in children and adolescents (Holzmann et al. 2019), a game with simple characteristics allows consolidating the learning of the information given about habits through brief tips. Young people prefer 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 22 intuitive and easy apps that can be managed quickly (Coughlin et al. 2015) and they find this in Healthy Jeart. Healthy Jeart has been developed by an inter-disciplinary team of experts and its design is endorsed by a continuous scientific work. The process required considerable involvement and effort, in addition to the time spent, which were difficult to maintain at some points. However, the main limitation of this study was related to financing. The scarce initial funding for such an ambitious project forced us to request cofunding in order to complete the production of the app. Similarly, new financing is now necessary to improve the app. This is a non-profit project, although the support of the public administration was essential. Now the app requires maintenance and constant updating of the contents, activities and challenges, including the game, in order to keep its interest, especially among the registered users. This leads us to highlight the need for support from the public administrations. This commitment is essential to achieve a real transfer of knowledge and retribution of all the work carried out to society. Healthy Jeart is a health promotion tool that was developed with low cost. However, its impact on the physical, psychological and social well-being of young people is expected to be high. The results from the test of a previous version indicate so. Currently, we are implementing a controlled experimental test with which this can be verified. With this project of analysis and intervention, we expect to increase the knowledge of a clearly expanding research field. Our main goal is to report how a mobile app with the characteristics of Healthy Jeart can contribute to adopting and maintaining healthy habits and evaluate the changes that could take place in them given the participation in interventions where this technology is used. The help and support received was considerable. Apart from the support of the public administration, it is important to acknowledge the involvement of the participating 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 23 educational centres. The project and the app were perceived as necessary tools in today’s society, thereby acceptance has been excellent from the beginning. References Abdullah, M. M. B., & Islam, R. (2011). Nominal group technique & its applications in managing quality in higher education. Pakistan Journal of Commerce & Social Sciences, 5, 81–99. doi: 10.1080/14703297.2015.1058721 Alfaro Gonzlez M., Vzquez Fernndez M. E., Fierro Urturi A., Muoz Moreno M. F., Rodrguez Molinero L., Gonzlez Hernando C., et al. (2015). Hbitos sexuales en los adolescentes de 13 a 18 aos. Rev Pediatr Aten Primaria, 17(67), 217-225. Brannon, E. E. & Cushing, C. C. (2015). A Systematic Review: Is There an App for That? Translational Science of Pediatric Behavior Change for Physical Activity and Dietary Interventions. Journal of Pediatric Psychology, doi: 10.1093/jpepsy/jsu108 Caon, M., Carrino, S., Condon, L., Ascolese, A., Facchinetti, S., Mazzola, M., Perego, P., Velickovski, F., Andreoni, G. & Mugellini, E. (2017). PEGASO Companion: A Mobile App to Promote Healthy Lifestyles Among Adolescents. In P. Perego et al. (Eds.), Wireless Mobile Communication and Healthcare. MobiHealth 2016. Lecture Notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering, pp. 53–61. Cham, Switzerland: Springer. Carr, G., Crocamo, C., Bartoli, F., Carretta, D., Schivalocchi, A., Bebbington, P. E. & Clerici, M. (2016). Impact of a Mobile E-Health Intervention on Binge Drinking in Young People: The Digital-Alcohol Risk Alertness Notifying Network for Adolescents and Young Adults Project. Journal of Adolescent Health, doi: 10.1016/j.jadohealth.2016.01.008 Carrión C., Arroyo Moliner, L., Castell, C., Puigdomènech, E., Gómez, S. F., Domingo, L. & Espallargues, M. (2016). Utilización del teléfono móvil para el fomento de hábitos saludables en adolescentes. Revista Española de Salud Pública, 90, 1-11. Chan, A., Kow, R. & Cheng, J. K. (2017). Adolescents’ perceptions on smartphone applications (apps) for health management. Journal of mobile technology in medicine, doi: 10.7309/jmtm.6.2.6 Coughlin, S. S., Whitehead, M., Sheats, J. Q., Mastromonico, J., Hardy, D. & Smith, S. A. (2015). Smartphone Applications for Promoting Healthy Diet and Nutrition: A Literature Review. Jacobs journal of food and nutrition, 2(3), 1-19. Delbecq, A. L., & Van de Ven, A. H. (1971). A Group Process Model for Problem Identification and Program Planning. The Journal of Applied Behavioral Science, doi: 10.1177/002188637100700404 Dute, D. J., Bemelmans, W. J. E. & Breda, J. (2016). Using Mobile Apps to Promote a Healthy Lifestyle Among Adolescents and Students: A Review of the Theoretical Basis and Lessons Learned. JMIR Mhealth Uhealth, doi: 10.2196/mhealth.3559. Edwards, E. A., Lumsden, J., Rivas, C., Steed, L., Edwards, L. A., Thiyagarajan, A., Sohanpal, R., Caton, H., Griffiths, C. J., Munafò, M. R., Taylor, S. & Walton, R. T. (2016). Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps. BMJ Open, doi: 10.1136/bmjopen-2016-012447 Eresta, M. J., Delpino, M. A. & Rivas, C. (2013). Relaciones afectivas y sexualidad en la adolescencia. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad. Flaherty, S. J., McCarthy, M., Collins, A. & McAuliffe, F. (2018). Can existing mobile apps support healthier food purchasing behaviour? Content analysis of nutrition content, behaviour change theory and user quality integration. Public Health Nutrition, doi: 10.1017/S1368980017002889 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 24 Garca Poole, C., Byrne, S. & Rodrigo, M. J. (2018). Adolescent lifestyle profiles and personal and community competences. European Journal of Developmental Psychology, doi: 10.1080/17405629.2017.1316258 Holzmann, S. L., Dischl, F., Schfer, H., Groh, G., Hauner, H. & Holzapfel, C. (2019). Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents. JMIR Form Res, doi: 10.2196/10284 Lazo Caparros, M. D., (2015). Impacto de la aplicacin mvil del Plan sobre Drogas del Gobierno de Espaa. Revista Española de Comunicación en Salud, 6(2), 157-65. Lee, A. M., Chavez, S., Bian, J., Thompson, L. A., Gurka, M. J., Williamson, V. G. & Modave, F. (2019). Efficacy and Effectiveness of Mobile Health Technologies for Facilitating Physical Activity in Adolescents: Scoping Review. JMIR mHealth and uHealth, doi: 10.2196/11847 Lee, C., Lee, K. & Lee, D. (2017). Mobile Healthcare Applications and Gamification for Sustained Health Maintenance. Sustainability, doi:10.3390/su9050772 Lucas Thompson, R. G., Broderick, P. C., Coatsworth, J. D., & Smyth, J. M. (2019). New Avenues for Promoting Mindfulness in Adolescence using mHealth. Journal of Child and Family Studies, doi: 10.1007/s10826-018-1256-4 Marston, H. R. & Hall, A. K. (2016). Gamification: Applications for Health Promotion and Health Information Technology Engagement. In D. Novák, B. Tulu & H. Brendryen (Eds.), Handbook of Research on Holistic Perspectives in Gamification for Clinical Practice. Hershey, USA: IGI Global. Martínez Villanueva, J. (2017). Obesidad en la adolescencia. Revista de Formacin Continuada de la Sociedad Espaola de Medicina de la Adolescencia, (3), 43-55. Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J. & Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Ann. behav. med., doi: 10.1007/s12160-013-9486-6 Moreno, C., Ramos, P., Rivera. F., Jiménez Iglesias, A., García Moya, I., Sánchez Quejía, I., Moreno Maldonado, C., Paniagua, C., Villafuerte Díaz, A. & Morgan, A. (2016). Los adolescentes españoles: estilos de vida, salud, ajuste psicológico y relaciones en sus contextos de desarrollo. Resultados del Estudio HBSC-2014 en España. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad. OEDT (2016). Alcohol, tabaco y drogas ilegales en España. Informe 2016. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad. Olaz, A. (2010). La Técnica de Grupo Nominal como Herramienta de Investigación Cualitativa. Bohodón Ediciones: Sevilla. Ortega, R. M., Lpez, A. M., Aparicio, A., Gonzlez, L., Navia, B., Perea, J. M., … & Labrado, E. (2016). Estudio ALADINO 2015: Estudio de Vigilancia del Crecimiento, Alimentación, Actividad Física, Desarrollo Infantil y Obesidad en España 2015. Madrid: Agencia Española de Consumo, Seguridad Alimentaria y Nutrición. Ministerio de Sanidad, Servicios Sociales e Igualdad. Pascual, F. (Ed.) (2017). Estudio Sociológico cualitativo sobre el consumo de alcohol y cannabis entre adolescentes y jóvenes. Barcelona: SOCIDROGALCOHOL. Rohrbaugh, J. (1981). Improving the quality of group judgement: Social judgment analysis and the Nominal Group Technique. Organizational Behaviour and Human Performance, doi: 10.1016/0030- 5073(81)90025-8 Sánchez Cruz, J. J., Jiménez Moleón, J. J., Fernández Quesada, F. & Sánchez, M. J. (2013). Prevalencia de obesidad infantil y juvenil en Espaa en 2012. Rev Esp Cardiol, 66(5), 371–376. Sardi, L., Idri, A. & Fernández-Alemán, J. L. (2017). A systematic review of gamification in e-Health. Journal of Biomedical Informatics, doi:10.1016/j.jbi.2017.05.011 Schoeppe, S., Alley, S., Rebar, A. L., Hayman, M., Bray, N. A., Lippevelde, W. V., Gnam, J. P., Bachert, P., Direito, A. & Vandelanotte, C. (2017). Apps to improve diet, physical activity and sedentary 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 25 behaviour in children and adolescents: a review of quality, features and behaviour change techniques. International Journal of Behavioral Nutrition and Physical Activity, doi: 10.1186/s12966-017-0538-3 Šmahel D., Machčkov H., Šmahelov M., Čevelček M., Almenara C.A. & Holubčkov J. (2018). Using Mobile Technology in Eating Behaviors, pp 101-118. In D. Šmahel et al. (Eds), Digital Technology, Eating Behaviors, and Eating Disorders. Cham, Suiza: Springer. Stoyanov, S. R., Hides, L., Kavanagh, D. J., Zelenko, O., Tjondronegoro, D. & Mani, M. (2015). Mobile App Rating Scale: A New Tool for Assessing the Quality of Health Mobile Apps. JMIR Mhealth and Uhealth, doi: 10.2196/mhealth.3422 Van Lippevelde, W., Vangeel, J., De Cock, N., Lachat, C., Goossens, L., Beullens, K., Vervoort, L., Braet, C., Maes, L., Eggermont, S., Deforche, B. & Van Camp, J. (2016). Using a gamified monitoring app to change adolescents’ snack intake: the development of the REWARD app and evaluation design. BMC Public Health, doi: 10.1186/s12889-016-3286-4 WHO (2014). Resumen: Salud para los adolescentes del mundo. Una segunda oportunidad en la segunda década. Departamento de Salud de la Madre, el Recién Nacido, el Niño y el Adolescente. Ginebra: WHO. Wong, M. W., Ye, Q., Kylar, Y. K. C., Pang, W. M. & Kwan, K. C. (2017). A Mobile Adviser of Healthy Eating by Reading Ingredient Labels. In P. Perego et al. (Eds.), Wireless Mobile Communication and Healthcare. MobiHealth 2016. Lecture Notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering, pp. 29–37. Cham, Suiza: Springer. Table 1. Emergent categories and subcategories. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65