Aim2Be, which will be evaluated in this RCT, was built on the foundational knowledge learned in the first generation of the program called LiGHT (Living Green Healthy and Thrifty) and the second generation of the program, called Aim2Be version 1 (v1). LiGHT was an 11-module online program that integrated lifestyle behavior modification principles with environmental and financial concerns to address childhood obesity among 10- to 17-year-old children and their families [32 (link)]. Modest and nonsignificant improvements in readiness to change were initially observed for both the child and parents, likely due to ceiling effects on the measure and small sample size (N = 17 child-parent dyads). However, the qualitative feedback (N = 10 child-parent dyads) suggested that the LiGHT approach held promise. Specifically, both children and parents indicated that they related strongly to the foundational approach of the LiGHT intervention, meaning they liked having behaviors linked with health, environmental, and financial concerns. The evaluation also uncovered key areas that needed further improvement, including making the program more visually appealing, adding more interactivity, and creating a sense of community for the users.
The second generation of the intervention transitioned from a web-based intervention to a mobile app (iOs and Android) and was renamed Aim2Be. For those who do not have a smartphone, Aim2Be has remained accessible as a web-based platform via the internet. Aim2Be became a gamified app that supports children and their families to initiate sustainable behaviors in four primary areas: healthy eating, active living, reducing screen time, and healthy sleeping habits. It retained its focus on linking behaviors with health and living green, as well as adding emphasis on healthy body image and strong self-esteem. While Aim2Be retained some core elements from the LiGHT program, it 1) became strongly grounded in theories of behavior change (i.e., being family-based, supporting the development of self-regulatory skills at both the individual and familial levels, and enhancing self-efficacy through graded tasks) [10 (link), 11 (link), 19 (link), 33 ]; 2) integrated principles of maintenance of health behaviors and as such it included self-regulatory processes that support intrinsic motivation [34 (link)–38 (link)]; 3) integrated gamification practices, which are designed to maximize both enjoyment and motivation [39 (link)]; 4) recognized the importance of body image and self-confidence in lifestyle management; 5) used the mHealth context to support self-regulatory processes [40 (link)]; 6) aligned with best clinical practices and guidelines in three areas (including a) the treatment of childhood obesity in Canada as it aligns with the curriculum of Canadian Weight Management programs (e.g., being family based, multi-behavioral, and focused on supporting skill development at the individual and familial levels); b) clinical guidelines for the management of childhood obesity as it integrates the central elements that need to be incorporated in these interventions (e.g., family focused, focused on improving lifestyle behaviors, skill based support) [41 (link)]; and c) Canadian health recommendations including the Canadian 24 Hour Movement Guidelines [42 (link)] and Canada’s Food Guide [43 ]); and 7) was designed specifically with and for children and their families (see details below).
Aim2Be was iteratively and incrementally developed. The first version of Aim2Be (v1) was field tested for 4.5 months among 301 teens between 14- and 17-years old and 315 parents. The quantitative evaluation revealed that teens who were moderately and/or highly engaged in the app (> 30 min of app usage) as compared to those with low engagement (≤ 30 min of app usage) significantly increased their motivation and self-efficacy to improve their dietary habits (i.e., limit sugar-sweetened beverages and increase intake of fruits and vegetables) and sedentary behaviors (i.e., limit screen time). At 4.5 months, children significantly increased their previous day’s intake of fruits and vegetables, decreased their consumption of 100% fruit juice, and reduced their screen time. In addition, parents who were more engaged with Aim2Be v1 reported significant improvements in the children’s dietary behaviors (i.e., increased intake of fruits and vegetables and decreased intake of sugar-sweetened beverages). Additionally, multiple rounds of qualitative evaluations were conducted among 36 teens/preteens and 24 parents. The qualitative evaluations included both focus groups and 2-week prototype testing, followed by semi-structured interviews. The results of these evaluations led to numerous improvements in Aim2Be including clarifying the overall purpose of Aim2Be, supplementing the tracking and check-in sections, adding more engaging features, and syncing the app with physical activity monitoring (i.e., Fitbit).
The conceptual framework of Aim2Be is shown in Fig.2 . At its core, the behavior change techniques (BCT) incorporated in Aim2Be are rooted in 1) Social Cognitive Theory (SCT) [44 (link)]; 2) the Player Experience and Need Satisfaction (PENS) model, which is an extension of the Self Determination Theory model for the gamified context and incorporates enjoyment to support intrinsic motivation and the basic psychological needs that promote intrinsic motivation (autonomy, relatedness, and competence/self-efficacy) [39 (link), 45 (link)]; and 3) the ACUDO framework [46 ]. The ACUDO framework, is a best practice framework developed by Ayogo Health Inc. [46 ] to promote engagement and enjoyment by: a) supporting Agency, b) incorporating Challenges, c) infusing Uncertainty, d) supporting self-Discovery and exploration, and e) adding fun Outcomes such as rewards. Specifically, Aim2Be includes strategies that target 1) gamified mediators of behavior change to ensure the experience is both enjoyable and engaging; 2) behavioral mediators that aim to activate self-regulatory skills and support the development of intrinsic motivation and increase self-efficacy as a way to support behavior change and ultimately support healthy body weights; and 3) environmental mediators because it is recognized that behavior change needs to be physically and emotionally supported in the familial environment and that social support from both peers and/or coach is also important to changing health behaviors (see Fig. 2 ).
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The second generation of the intervention transitioned from a web-based intervention to a mobile app (iOs and Android) and was renamed Aim2Be. For those who do not have a smartphone, Aim2Be has remained accessible as a web-based platform via the internet. Aim2Be became a gamified app that supports children and their families to initiate sustainable behaviors in four primary areas: healthy eating, active living, reducing screen time, and healthy sleeping habits. It retained its focus on linking behaviors with health and living green, as well as adding emphasis on healthy body image and strong self-esteem. While Aim2Be retained some core elements from the LiGHT program, it 1) became strongly grounded in theories of behavior change (i.e., being family-based, supporting the development of self-regulatory skills at both the individual and familial levels, and enhancing self-efficacy through graded tasks) [10 (link), 11 (link), 19 (link), 33 ]; 2) integrated principles of maintenance of health behaviors and as such it included self-regulatory processes that support intrinsic motivation [34 (link)–38 (link)]; 3) integrated gamification practices, which are designed to maximize both enjoyment and motivation [39 (link)]; 4) recognized the importance of body image and self-confidence in lifestyle management; 5) used the mHealth context to support self-regulatory processes [40 (link)]; 6) aligned with best clinical practices and guidelines in three areas (including a) the treatment of childhood obesity in Canada as it aligns with the curriculum of Canadian Weight Management programs (e.g., being family based, multi-behavioral, and focused on supporting skill development at the individual and familial levels); b) clinical guidelines for the management of childhood obesity as it integrates the central elements that need to be incorporated in these interventions (e.g., family focused, focused on improving lifestyle behaviors, skill based support) [41 (link)]; and c) Canadian health recommendations including the Canadian 24 Hour Movement Guidelines [42 (link)] and Canada’s Food Guide [43 ]); and 7) was designed specifically with and for children and their families (see details below).
Aim2Be was iteratively and incrementally developed. The first version of Aim2Be (v1) was field tested for 4.5 months among 301 teens between 14- and 17-years old and 315 parents. The quantitative evaluation revealed that teens who were moderately and/or highly engaged in the app (> 30 min of app usage) as compared to those with low engagement (≤ 30 min of app usage) significantly increased their motivation and self-efficacy to improve their dietary habits (i.e., limit sugar-sweetened beverages and increase intake of fruits and vegetables) and sedentary behaviors (i.e., limit screen time). At 4.5 months, children significantly increased their previous day’s intake of fruits and vegetables, decreased their consumption of 100% fruit juice, and reduced their screen time. In addition, parents who were more engaged with Aim2Be v1 reported significant improvements in the children’s dietary behaviors (i.e., increased intake of fruits and vegetables and decreased intake of sugar-sweetened beverages). Additionally, multiple rounds of qualitative evaluations were conducted among 36 teens/preteens and 24 parents. The qualitative evaluations included both focus groups and 2-week prototype testing, followed by semi-structured interviews. The results of these evaluations led to numerous improvements in Aim2Be including clarifying the overall purpose of Aim2Be, supplementing the tracking and check-in sections, adding more engaging features, and syncing the app with physical activity monitoring (i.e., Fitbit).
The conceptual framework of Aim2Be is shown in Fig.
Conceptual framework of Aim2Be
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