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Design and Evaluation of a Mobile Snack Application for Low Socioeconomic Status Families Design and Evaluation of a Mobile Snack Application for Low Socioeconomic Status Families by Danish U. Khan B.E., NED University of Engineering and Technology, 2005 M.S., University of Colorado Boulder, 2008 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Computer Science 2013 This thesis entitled: Design and Evaluation of a Mobile Snack Application for Low Socioeconomic Status Families written by Danish U. Khan has been approved for the Department of Computer Science Prof. Katie A. Siek Prof. Clayton H. Lewis Prof. Dirk C. Grunwald Dr. Stephen E. Ross Prof. Kenneth M. Anderson Date The final copy of this thesis has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline. iii Danish U. Khan, (Ph.D., Computer Science) Design and Evaluation of a Mobile Snack Application for Low Socioeconomic Status Families Thesis directed by Prof. Katie A. Siek Low socioeconomic status (SES) populations are prone to higher risks of acquiring chronic diseases including cardiovascular disease, diabetes, and hypertension. Among the major causes are individuals' everyday health-related decisions that affect their long term health, in particular their dietary and physical activities. In my research, I designed a sociotechnical intervention to improve the awareness and healthiness of snacks for a low SES population. In this research, I employed participatory and user-centered design techniques by engaging the population through a user needs assessment, prototype evaluation, and a pilot intervention field- trial study. For the needs assessment study, I used multimedia-elicitation interviews to understand the health routines of the target population. Needs assessment findings showed that generally the population had poor dietary habits and unhealthy snacking was a major contributing factor. I also found that the target population used mobile phones that were their preferred platform for a sociotechnical dietary intervention. Based on these findings, I evaluated multiple prototype designs with twenty six caregivers to explore the usability and demographic-specific interfaces of the prototypes. I found that the parents preferred a basic, management-style design, while the teenagers wanted gaming mechanics in the application. The optimal prototype designs for each group were developed into a functional mobile phone application that was evaluated by ten low SES families during a twelve-week field trial. At the end of the field trial, the intervention group's diet was significantly healthier than the control group. The low SES families consistently used the mobile application with demographic-specific interfaces. While the parents found value in managing their family health, the teenagers were motivated by snacking game and competed enthusiastically against their parents. Both parents and teenagers mentioned that the application made them aware about their snacking, and provided useful information about healthier snacks. iv While my research lays the foundation for mobile snack application design for low SES pop- ulations, it provides many future research directions such as investigation of various gaming inter- faces (e.g., competition versus cooperation), theory driven application designs, considerations for multicultural community intervention design, dietary information retrieval systems, complex snack rating mechanisms, and flexible interface relevance. Dedication To my parents, wife, daughter, and sisters who have always loved me. vi Acknowledgements I first thank the Almighty Allah, for providing me the strength and motivation to work for low socioeconomic status populations to improve their health. To my parents, Sohail and Talat, who raised me with love: thank you for your unconditional love, you have always encouraged me to achieve my dreams and go the extra mile. To Fatima, my wife and best friend: thank you for being patient and supportive throughout my Ph.D. Your love and support especially helped me when the chips were down. To my daughter, Hania, who will turn one the day before my defense: you are the love of my life, your cute smile makes me realize how blessed I am, and refreshes me for the next day. To my sisters, Sarwat and Sana, you have always loved me and taught me so many things. I thank my advisor, Katie Siek, for mentoring and guiding me throughout my Ph.D. It is a privilege to be your first Ph.D. student. To my committee: Clayton Lewis, Stephen Ross, Kenneth Anderson, and Dirk Grunwald, thank you for your advice and ideas throughout my research. To my lab fellows: Swamy Ananthanarayan, Christopher Schaeufbauer, Amy Lee, and Allison Brown: thank you for working with me, you have made my entire Ph.D. journey a memorable experience. I also thank the Bridge Project personnel, who went out of their way to coordinate with the participants, and facilitate my research studies. Thanks to all the participants for participating in my research. Finally, I would like to thank the National Science Foundation for supporting and funding my research. vii Contents Chapter 1 Introduction 1 1.1 Contribution . .3 1.2 Research Questions . .5 1.3 Road Map . .5 2 Background and Motivation 7 2.1 Target Population . .7 2.2 Technology Access and Narrowing Digital Divide . .8 3 Related Work 9 3.0.1 Technological Interventions to Improve Dietary Behavior . 10 3.0.2 Health-related Technologies for Low SES Populations . 14 3.0.3 Games for Improving Dietary Behavior . 15 3.0.4 The Role of Family in Health Interventions . 17 3.0.5 Automatic Dietary Assessment . 18 4 Previous Work 19 4.1 Focus Group and Interviews . 19 4.1.1 Forced Precontemplation . 19 4.1.2 Unabsorbable Information . 20 viii 4.1.3 Taste-based Food Choices . 20 4.1.4 Barriers to Common Health Solutions . 20 4.2 Participatory Design Workshops . 21 4.2.1 Word Association Exercise . 21 4.2.2 Augmented Objects Exercise . 21 4.3 Discussion: The Role of Technology . 22 4.4 Proposed Approach . 22 4.4.1 Multimedia-Elicitation Interviews . 22 4.4.2 Prototype Evaluation . 23 4.4.3 Field Trial . 23 5 Multimedia Elicitation Interviews 24 5.1 Study Objectives . 25 5.2 Participants . 25 5.3 Methods . 25 5.4 Analysis . 30 5.5 Results . 31 5.5.1 Usage Patterns . 31 5.5.2 Overview of the Knowledge-Practice-Reflection Cycle . 33 5.5.3 The Need and Motivation to Monitor Health . 38 5.5.4 Preferred Health Metrics to Monitor . 39 5.5.5 Technological Platforms . 39 5.5.6 Granularity of Capturing and Viewing Health Data . 40 5.5.7 Visualizing Single Health Data Stream . 41 5.5.8 Visualizing Multiple Health Data Streams . 41 5.5.9 Prototype Interfaces Designed by the Caregivers . 42 5.6 Discussion . 43 ix 5.6.1 Diet and Technology . 44 5.6.2 The Role of Culture . 44 5.6.3 Gradual Change . 45 5.6.4 Health Management Application . 46 5.7 Conclusion . 48 6 Prototyping 50 6.1 Behavioral Change Theories . 50 6.1.1 Health Belief Model . 51 6.1.2 Social Cognitive Theory . 51 6.1.3 Theory of Reasoned Action . 51 6.1.4 Elaboration Likelihood Model . 52 6.1.5 Transtheoretical Model of Behavioral Change . 52 6.1.6 Precaution Adoption Process Model . 52 6.1.7 Transportation Theory . 53 6.2 Prototypes . 53 6.2.1 Snack Manager . 53 6.2.2 Snack Educator . 56 6.2.3 Health Heroes Prototype . 58 6.3 Participant Demographics . 61 6.4 Methods . 62 6.5 Results . 64 6.5.1 Caregiver Preferences . 64 6.5.2 Snack Manager . 66 6.5.3 Lifespan . 69 6.5.4 Snack Educator . 71 6.5.5 Health Heroes . 72 x 6.6 Discussion . 73 6.6.1 Management and Engagement . 74 6.6.2 Healthiness Visualization Needs . 75 6.6.3 Price: The Changing Requirement . 76 6.6.4 Designing for Sensitivity and Nurturing Health Values . 76 6.6.5 Evaluating Gaming Applications . 77 6.7 Conclusion . 77 7 Field Trial 79 7.1 Snack Buddy - Mobile Phone Application Design . 79 7.1.1 Primary Caregiver Interface . 81 7.1.2 Secondary Caregiver Interface . 83 7.2 Application Architecture . 90 7.2.1 Server . 90 7.2.2 Client . 90 7.2.3 Server-side Monitoring Tool . 92 7.3 Methods . 95 7.3.1 Beta Field Trial . ..
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