Six focus groups, each with between 4 and 7 participants, were held virtually over a two-week period during July and August 2021. Initially we recruited 36 participants but one participant did not attend the scheduled focus group and another decided to withdraw from the discussion, therefore a total of 34 participants (mean ± SD; aged 45 ± 3.6 years; 64.7% females) were included (Table 1).

Table 1 Characteristics of focus group participants (n = 34)

Thematic analysis

Five main themes were identified through thematic analysis: (i) holistic wellbeing is central to healthy living, (ii) encouraging uptake of a mobile health intervention, (iii) trying out a mobile health intervention is one thing, sticking to it long term is another, (iv) perceptions of chatbots as a tool to support healthy lifestyle behaviour and (v) sharing health-related data is OK, but with conditions.

Theme 1: holistic wellbeing is central to healthy living

Holistic wellbeing was the key overarching theme when discussing the topic of healthy lifestyle. Participants felt strongly that healthy living requires a balance between both physical and mental health, as well as activities of daily life. They viewed exercise, nutrition, and sleep as core pillars, or the foundations, of a healthy lifestyle but they also identified several other aspects of life that are important. For example, having social connections and a good support network, paying attention to emotional and mental wellbeing, being surrounded by positivity, spending time on spiritual practice, or having security and certainty in life were discussed.

Quote: “Healthy lifestyle has two aspects, one is a physical health, which is, of course, your diet and your exercise and the other one is your emotional health, which means to be spending time with your loved one, having some ‘me time’. So, to me that is healthy lifestyle, so everything has to be in balance.” (P32, Chinese Female aged 37 years).

Quote: “I would think that it is more than the physical and the food and the sleeping, for example, to me, also making meaningful connections to people around me.” (P29, Chinese Male aged 41 years).

Participants identified three support mechanisms that they felt would help them to live a healthy lifestyle. These were trained professionals, peers or family members, and the internet. Although professionals were perceived to be the best support for mental health, there was the view that mental health stigma prevents people from seeking their support due to concerns that a diagnosis could lead to negative consequences, for example on future employment. Instead, for mental health support, people may rely more on the internet, family and friends, or a support group.

Quote: “for the mental health challenges right, if they are not open for professional help, I’ll encourage them to join mental health support groups, you know there’s those available where diagnosis is not required, because of the stigma.” (P5, Chinese Female aged 39 years).

Barriers, facilitators, and strategies

The identified barriers, facilitators, and strategies to healthy living are summarized in Table 2. In general, participants felt people know how to lead a healthy lifestyle, but what prevents them from implementing healthy activities is a lack of motivation, discipline, or willpower. They described competing priorities, such as work commitments and taking care of family, as taking up most of their time, with a lack of personal time to engage in healthy activities. Therefore, participants felt a better work-life balance would facilitate healthy living and perhaps allow them the time to commit to a healthy lifestyle.

Table 2 Themes, sub-themes, and example quotes in relation to the participants’ perceived barriers, facilitators, mixed factors, or strategies

Environmental factors were viewed as both barriers and facilitators to healthy lifestyle in Singapore. For example, residents generally have good access to parks and outdoor activity spaces, such as outdoor gyms, and fitness centres are generally low cost. However, the weather conditions limit outdoor activity to the early morning or evening, when temperatures are cooler. Participants also explained that the food environment in Singapore does not promote healthy eating, as unhealthy food is cheaper and highly available, compared to healthy food.

Social influences were also perceived as creating both barriers and facilitators to healthy eating and participation in exercise and physical activity. Participants talked about how food choices are influenced by what others are eating or the food preferences of others, both when dining out and preparing food at home. They also talked about how involving family and friends in physical activity can motivate them to be more active.

Participants also described the actions they were already taking or could take, to lead a healthy lifestyle. Dietary strategies included making conscious diet choices, for example eating more balanced meals, ordering less ‘take away’ food, and cooking at home. Exercise strategies focused on integrating movement into daily activities, for example walking after meals and taking activity breaks during the workday. Different psychological strategies included setting goals, following a routine, journaling, and spiritual rituals like meditation and praying. Finally, time management strategies, including a focus on work-life balance and planning ahead for healthy eating and physical activity, were named by the participants.

Theme 2: encouraging uptake of a mobile health intervention

Theme 2 discusses the factors influencing the initial uptake of mobile health interventions. Participants’ comments were largely in relation to digital health promotion programmes offered by the Singaporean Government’s Health Promotion Board (HPB), although opinions on other commercially available apps were also discussed. In general, participants were open to using digital health interventions and apps. They acknowledged that the Singapore Government has made significant effort to promote health through digital programmes and that the incentives offered with these programmes (e.g., offering free wearable trackers) are effective in getting people to sign up initially. Some also commented that programmes or apps that are popular, and that many people are talking about, encourage wider uptake. Apps with essential features linked to lifestyle behaviours, for example, booking systems for fitness classes, or tracking body weight with a linked digital scale, also have higher uptake.

Quote: “I honestly feel that HPB’s model (free tracker coupled with incentives) is pretty effective and has seen a very good adoption rate.” (P24, Indian Male aged 38 years)

Quote: “For me, I feel probably you need to make the app more popular first, maybe some incentive to initially just jump start, like everyone now notices the [online retailer] app. You need to make the app popular so that word of mouth or that you get more and more people use it then. (P34, Chinese Male aged 42 years)

Quote: “I was introduced to it [Healthy 365 app] because there’s a dance class that goes on right underneath my window, and that was like so attractive, so I just appeared then they told me, oh yeah you can dance here, and you can download this app.” (P9, Indian Female aged 42 years)

Barriers, facilitators, and strategies

The identified barriers, facilitators, and strategies for the uptake of mobile health interventions are summarized in Table 2. In terms of barriers, participants found that the type of user could prevent uptake, for example, people who do not like to wear watches or activity trackers or those who are less technically savvy. They also highlighted decreased trust in health programmes with corporate links or sponsorships, as they found the backing of certain companies stood in direct opposition to the proclaimed health objectives of the programmes (for example in the case of fast-food companies). One key facilitator to the uptake of mobile health interventions was accessibility. Programmes that offer a digital platform that can be accessed by anyone, regardless of demographic or background, were seen as highly inclusive and more likely to be used. As an example, access to free apps and activity trackers, as in the case of the National Steps Challenge in Singapore, was seen as an enabler to join the programme.

The marketing strategies and outreach efforts used to encourage uptake of mobile health interventions were seen as both a barrier and a facilitator. On the one hand, roadshows and the use of radio jingles were mentioned as memorable tools that convinced people to join. On the other hand, one participant said that it was often difficult to find further information about ongoing programmes and it was too effortful to sign-up to participate. Similarly, there were mixed views regarding the cost of commercial apps. While participants felt cost was a limiting factor in the uptake and long-term use of commercial apps which ultimately led the abandonment of the app, they were also dissatisfied with the limited features available with free apps. Still, if apps were able to offer the same service as comparable offline services, such as receiving support from a health professional, participants saw cost benefits for the app.

Strategies for the uptake of mobile health interventions were centred around ways to reach people. Participants viewed places visited frequently by people, such as supermarkets, schools, or workplaces, to be the best places to reach and engage people with mobile health initiatives. In addition, participants felt certain individuals, such as doctors, friends, or community support groups, would be best placed to convince people to use mobile health interventions. Consistent and persistent messaging about a mobile health intervention over a long period of time was also mentioned as a way to encourage uptake.

Theme 3: trying out a mobile health intervention is one thing, sticking to it long term is another

Theme 3 explores user experience and factors influencing long-term engagement with mobile health interventions. Overall, participant’s perceived mobile health interventions as useful and effective, highlighting the benefits of certain features like providing free apps and activity trackers, being able to collect rewards, and using the technology to connect with group activities and workshops.

Quote: ““Lose to Win” is also organized by the Health Promotion Board…I took part in a few seasons, and I think it was really, really helpful. The first time when I take part in it they organize you into groups and then you meet regularly to exercise together, and also on nutrition workshops and yeah talks and workshops, which is very helpful. I got to know a few friends from that programme.” (P2, Chinese Female aged 46 years)

Participants mentioned that the novelty and excitement of a new app encouraged them to use it more in the beginning, but after some time, the novelty effect would wear off and they would either stop using the app as frequently or give up using it altogether.

Quote: “that’s quite exciting for the first two seasons of this ‘National Steps Challenge’, then after that, even though I sign up on the latest ‘National Steps Challenge’ but because I’m not clocking much [steps], I kind of also semi give up, yeah [laughs]. So yeah, the initial excitement has gone.” (P2, Chinese Female aged 46 years)

Quote: “I think the initial stage, because of the novelty people will get a tracker try to clock 10,000 steps, every day, but after a number of days, it wears off, so once the novelty wears off, we are back to our usual: people who are active remain active, people who are not active will still be not active because it’s like there’s no more incentive anymore really.” (P32, Chinese Female aged 47 years)

Barriers, facilitators, and strategies

The identified barriers, facilitators, and strategies linked to long-term engagement with mobile health interventions are summarized in Table 2. Participants felt technical issues, for example, problems synching apps with trackers or measurement inaccuracies, and high levels of user burden, such as when manually tracking dietary intake, were key barriers to continued engagement with apps. Tracking health and behaviours, particularly via passive sensing, and being able to compare data with others, were seen as facilitators to engagement. Additionally, social influences were identified as facilitating engagement in two ways, first in the sense that people want to use an app that everyone else is using, and second, it can be motivating when other family members and friends are using the same app and provide support to engage in healthy activities.

Rewards and incentives via mobile health interventions were seen as both facilitators and barriers to engagement with healthy lifestyle behaviours. On the one side, participants said incentives, such as receiving vouchers for performing healthy activities, can be effective in engaging people with a mobile health intervention and help to motivate them to change their behaviours. On the other side, they acknowledged that this form of extrinsic motivation is unlikely to work long-term and can lead to users abusing the system. For example, when rewards and incentives are no longer available users become disengaged, suggesting they will only perform the desired behaviours when an incentive is involved.

There were also mixed views on tailoring and personalisation of app content and features. Although tailoring was perceived as a very desirable feature, participants commented that existing apps often take a ‘one-size-fits-all’ approach and, while that approach might work for some people, it is unlikely to work for the majority. In general, if a mobile health intervention is not tailored, personalized, or bespoke to the individual, people will eventually abandon it.

Participants identified several strategies that they felt would improve engagement with mobile health interventions. Social strategies included collaborating as a group with family and friends to achieve prizes or using peer pressure to help drive behaviour change. In relation to incentives, while they were identified as creating both barriers and facilitators to longer-term engagement, participants still felt that they could be used to further facilitate long-term engagement. For example, they suggested different models of incentivisation such as delayed rewards or only allowing users to redeem points against healthier choice products. Regarding desirable features, participants highlighted the importance of personalization, whereby an app can cater directly to a user’s specific needs and tailor support or content as needed. They also discussed a desire to be able to track and visualize their progress and achievements easily. In addition, apps should be extremely easy to use, offer multiple health and wellbeing services, and integrate different data sources in one place to reduce burden on participants.

Theme 4: perceptions of chatbots as a tool to support healthy lifestyle behaviour

Participants’ views on chatbots were largely based on their experiences using customer service-related support. They had a negative perception of chatbots, perceiving them as useless, and described the process of interacting with them as frustrating. Specifically, chatbot interactions are time-consuming and the chatbot itself is often unable to understand questions or provide helpful answers. These issues were perceived to have a demotivating effect on users and made them sceptical about how useful a chatbot would be in the health context.

Quote: “I think it’s just based on past or present experiences that we had on chatbots, they’re usually not answering your question directly, I think a lifestyle, digital coach, whether health exercises or even mental health, I guess, I wouldn’t want to use it.” (P3, Chinese Female aged 48 years)

Quote: “Well, if it is still not a real person, then after all it is programming, so I wouldn’t say that I have much confidence in it, because, after all, for everyone the problem is unique.” (P32, Chinese Female aged 37 years)

Participants were also concerned that chatbots, or digital interventions more generally, might be used to replace face-to-face services and could lead to job losses for certain professionals, like psychologists.

Quote: “…might people lose their job or get replaced? If you can understand yourself, why would we need a doctor, why would we need a psychologist, physically?” (P26, Malay Female aged 38 years)

While participants were open to the idea of a chatbot supporting them with certain health issues or behaviours, there was concern that, for mental health support, a chatbot might not only be demotivating but also problematic and that AI might never be able to replace a human being.

Quote: “One of the bad things about digital health coaching is that it can come across as slightly impersonal and the other thing is that it may try to be motivational but it might end up having a really opposite effect” (P11, Chinese Female aged 37 years)

Quote: “For me, I think, I would like to know whether it is a chatbot or real person. I mean if it’s for food, okay lah, just a chatbot will do. But if it’s a mental health coach, I would prefer a human being. I mean a real-life human behind the chat. I mean, that’s why I feel that robotic or AI can never replace a human being, I’ll need the touch, yeah, so I think for mental health, I prefer a human being behind it.” (P1, Chinese Female aged 46 years)

Quote: You can have the Doctor Google or Alexa, you know, answering your queries anytime of the day, but if you’re talking about psychological well-being it’s pretty hard to trust just a robot, you know, answers which are like generic anyway.” (P23, Chinese Female aged 46 years)

However, they also acknowledged that the technology is still in its infancy and apps using digital health coaches could have potential due to their availability, accessibility, and cost-effectiveness when compared to offline options.

Quote: “So I mean of course there are like some established chatbots where people use it so much that the AI is good enough to be able to give good answers, but it always takes – yeah I mean it’s a good time to start – but it always takes a while before the data collected is good enough for it to give reasonably good answers.” (P6, Chinese Female aged 39 years)

Quote: “compared to like a physical coach, right, I think I would be more receptive to having a digital coach. Simply because of the availability, the accessibility and then I think working with a digital coach would also be more cost effective. In a sense, I think, probably for a digital coach, at most, the cost involved probably would be from your monthly subscription if it’s chargeable in that sense. But then, whereas you know if you have a physical coach, I think in the terms of costs here will be higher. So in that sense, I think I would be more receptive towards the app.” (P24, Indian Male aged 38 years)

Potential strategies to improve chatbots for the purpose of digital health coaching were largely focused on the qualities of the chatbot and the type of support that the chatbot could provide. For example, the chatbot should be empathetic, interactive, encouraging, and helpful, like a virtual friend who can provide motivational support and makes personalized health suggestions based on current progress. Participants also suggested giving users different ways of interacting with the chatbot, for example through speech or text, offering free trial periods to test out the chatbot, and providing an option to link users to real-life coaches.

Quote: “…the interactive element there, so if a digital health assistant wants to maybe be a little bit more effective, it should be your friend. It shouldn’t be something that is very much like your doctor sitting there and then looking at vitals. It should be the friend who says ‘hey, wanna come with me today and let’s go for just a short walk?’ and then after that before you know it, that app has brought you on a slightly longer walk, than the short walk that you originally wanted. And then the app says ‘hey I had lots of fun with you’ and all that kind of thing, so it has to have a very human side to it in order to be effective.”

Theme 5: sharing health-related data is OK, but with conditions

Participants were largely unconcerned about health-related data sharing, especially if they could see a benefit for them or the wider community. However, this sentiment was conditional on three aspects: (i) who will have access to the data, (ii) how it will be stored, and (iii) for what purpose it will be used. Participants needed to be able to trust the entity accessing and using their data. In this regard, government agencies were viewed as more trustworthy than private companies, as the latter were perceived to benefit from the data themselves by monetizing it. Participants were generally happy to share their data if it was aggregated, anonymized, and securely stored. Participants highlighted the importance of being informed about the proposed use of their data and being explicitly asked to provide their consent for this use.

Quote: “I know I’m sharing my personal data for the better of the community.” (P21, Chinese Male aged 47 years).

Quote: “I think what’s important is to generate more trust or like you know, for us to want to be more willing to share data, we’d like to know, what actually is being done with the data, like, why do you need this information and what’re you going to do with it and what do I get back in return for sharing that bit of data and how it can help me? (P6, Chinese Female aged 39 years).


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