JMIR Publications

ABSTRACT

Background:

Eating disorders are severe mental health conditions driven by psychological, social, and emotional factors and have the highest mortality rate of any psychiatric disorder. Evidence-based theory-driven behavior change interventions are the gold standard; however, access to treatment remains low. Whilst digital interventions, such as apps, may provide accessible support for individuals with mild to moderate eating disorders, their development has rarely been guided by systematic behaviour change frameworks. Many interventions lack a robust theoretical foundation, insufficiently target the specific mechanisms driving eating disorder behaviours, and are commonly designed without involvement of people with lived experience.

Objective:

This study aimed to identify priority behavioural change targets for ED apps by capturing lived experience perspectives on the psychological, behavioural, and contextual factors maintaining disordered eating and driving app engagement. Using the COM-B and TDF frameworks, we mapped these determinants to identify where and how apps can most effectively enhance capability, opportunity, and motivation. Participants were male and female adults with lived experience of an eating disorder, including minority ethnic backgrounds, to ensure the proposed targets reflected diverse, real-world needs.

Methods:

Six small focus groups (2-5 participants per group) were conducted with 13 female and 5 male adults living in the UK from diverse cultural backgrounds with lived experience of an eating disorder. Discussions explored (1) the psychological, social, and environmental determinants underpinning participants’ disordered eating behaviours, and (2) the behavioural and contextual mechanisms influencing engagement with an ED app. A hybrid deductive-inductive thematic analysis was performed using two complementary behavioral models: the COM-B model and the Theoretical Domains Framework. Resulting themes were mapped onto evidence-based Behavior Change Techniques using the Theory and Techniques Tool (TATT) to identify priority intervention targets for digital implementation.

Results:

This study identified clear behaviour change targets for digital ED interventions, identifying requirements in 5/6 (83%) COM-B domains and 13/14 (93%) associated TDF domains for changing maladaptive eating disorder behaviors and 5/6 COM-B (83%) and 12/14 TDF domains (86%) for sustaining app engagement. Crucially, it demonstrated that effectiveness depended not only on which behaviour-change techniques were included but on how they were implemented, as poorly delivered techniques can undermine engagement and exacerbate symptoms. Although social support and emotional regulation were key influences, less commonly targeted domains, such as social/professional role and identity, belief in capabilities emerged as powerful drivers in this population. Gender and cultural background moderated almost every domain, highlighting the necessity of personalized, adaptive delivery. Reinforcement was universally valued, yet there were variations in terms of which motivational techniques they preferred, reinforcing that one-size-fits-all approaches are inadequate.

Conclusions:

As the first study to apply the COM-B and TDF frameworks to both disordered eating behaviours and app engagement, it identifies previously overlooked behavioural mechanisms and design pitfalls, including how poorly delivered techniques can undermine recovery. It provides a practical blueprint for developing safer, more personalized, and behaviourally effective ED apps. Significant work is needed to advance apps in line with these recommendations, supported by ongoing collaboration with diverse people with lived experience.