JMIR Publications

ABSTRACT

Background:

Eating disorders (EDs) are severe mental health conditions driven by psychological, social, and emotional factors and with the highest mortality rate of any psychiatric disorder. Targeted behavior change interventions are the gold standard; however, access to treatment remains low. Whilst existing digital interventions, such as apps, may provide accessible support for individuals with mild to moderate eating disorders, many lack a strong theoretical foundation and do not address the multifaceted drivers of ED behaviors.

Objective:

This study applied behavior change theory to identify key mechanisms of ED behaviors and app engagement with male and female adults with lived experience of an eating disorder. These insights can inform the development of effective, engaging evidence-based eating disorder apps.

Methods:

Six small focus groups (2-5 participants per group) were conducted with adults from diverse cultural backgrounds with lived experience of an eating disorder. The discussion involved: (1) factors which impacted on their disordered eating behaviors and (2) factors which influenced engagement with an ED app. A deductive thematic analysis was performed using two complementary behavioral models: the COM-B model (Capability, Opportunity and Motivation impacting Behavior) and the Theoretical Domains Framework (TDF). Findings were mapped onto Behavior Change Techniques (BCTs) using the Theory and Techniques Tool (TATT).

Results:

The behavioral analysis highlighted the need to target 5/6 COM-B domains and 13/14 (93%) associated TDF domains to support behavior change and reduce maladaptive eating disorder behaviors. Similarly, app engagement was shaped by 5/6 COM-B domains and 12/14 (86%) associated TDF domains. While social support and emotional regulation were key influences, less frequently mentioned factors, such as role, identity, and belief in capabilities also significantly shaped behavior for relevant participants. Gender and cultural factors influenced eating disorder behaviors, underscoring the need for personalized and adaptive interventions. Reinforcement was valued by all participants however, there were differences in terms of the motivational techniques they found helpful.

Conclusions:

As the first study to apply the COM-B and TDF frameworks to eating disorders app development, clear behavioral targets for impactful app development were identified. ED apps have historically been designed primarily for Western women but need to be tailored to the diverse needs, preferences, and lived experiences of all users including both men and women and those from diverse cultural backgrounds. Apps should address cognitive and emotional barriers and incorporate clear reinforcement strategies to address the psychological, social, and contextual factors that influence engagement. Strategies must be tailored to individuals’ needs and adapt dynamically to provide timely and appropriate support.