College of Policing

Aug 4, 2023

October 04, 2022 . A Tailored mHealth App for Improving Health and Well-Being Behavioral Transformation in UK Police Workers: Usability Testing via a Mixed Methods Study A Tailored mHealth App for Improving Health and Well-Being Behavioral Transformation in UK Police Workers: Usability Testing via a Mixed Methods Study Authors of this article: 2Bournemouth University, Faculty of Health and Social Sciences, Bournemouth, United Kingdom 3Hampshire Constabulary, Southampton, United Kingdom Corresponding Author: Bournemouth Gateway Building Bournemouth, BH8 8GP Abstract Background: When considering the policing environment of 2022, many roles previously in the domain of warranted officers (police officer) are now performed by nonwarranted police staff equivalents. These police staff roles have expanded rapidly into other areas such as investigations, custody, and contact management, which were traditionally seen as police officer functions and put staff under some of the same stresses as police officers. A UK police force requested help in investigating technologies that could be used to improve health and well-being for both officers and staff. Objective: The aim of this study was to create a health and well-being app for police officers and staff, which considered the unique requirements of the users throughout the designing, building, prototyping, and testing stages. Methods: This study involved quantitative approaches (demographic web-based survey questions and the System Usability Scale) and qualitative approaches (open web-based survey questions and semistructured interviews). Unsupervised usability testing of a prototype app was undertaken by members (N=48) of the commissioning client using their smartphones. After completing a preregistration application for screening purposes, participants downloaded a trial version of the app. Then, they completed a web-based questionnaire after testing the app for 10 days. A subsample of participants (9/48, 19%) was interviewed. Deductive thematic analysis was undertaken to identify key themes and subthemes. Results: Data collected during usability testing concerned the 6 domains of the app—food and diet, activity, fluid intake, sleep, good mental health, and financial well-being—and informed the creation of improved design during prototyping. Some usability and design issues and suggestions for improvements were also addressed and implemented—including shift management and catch-up cards—during this cycle of development. Conclusions: This study highlights the importance of coparticipation with officers and staff across the entire development cycle, to coproduce a human-centered design methodology to enable the development of a considered and user-centered solution. It demonstrates the need for producing a multifunctional tool rather than focusing purely on an individual element for this user group. It also highlights how linking and being able to track optional, personalized elements of health data against one another, cross-referenced to individual shift patterns, might help to inform and provide users with a chance for reflection and therefore influence behavior change. JMIR Hum Factors 2023;10:e42912 Overview As our previous study has highlighted, there are currently a number of health and fitness solutions available on multiple platforms in use by police officers and staff [ 15 ]. Notably, most apps focus on a particular element of health and well-being. They have not been designed to address the specific issues that police officers and staff face, nor are they configurable for the types of routines and working patterns that the users regularly encounter [ 31 ]. Recent literature reviews—such as a 2020 review of studies of gamification and mobile health (mHealth) apps for emergency service personnel (ESP) and police officers across 6 major databases—have highlighted a lack of literature in this area for these groups [ 32 ]. To meet the study objectives, where possible, user suggestions were implemented for improvements during the development process. The current app is designed to focus on the individual domains that comprise overall wellness—physical, mental, and financial well-being—of police personnel. Consideration of the shifts undertaken was at its center, as shift work patterns make tracking more difficult for this profession. Overall, feedback about the app was positive based on the SUS score received. Users particularly liked the shift manager, mood diary, trackers to log fluid intake and alcohol consumption, and the relevant supporting information made available for easy access. Approximately half (24/48, 50%) of the users thought that the app was easy to use, and this was considered to be the main reason for liking the app. However, there are still various improvements that need to be actioned. Some of these are improvements in shift manager, giving the ability to create bespoke shift patterns, functioning of the calendar feature of the existing trackers, and display of information to make it easy on the eye. Moreover, there are additional requests by participants to add new features to the app such as trackers to record activity and food intake and reminders to prompt them regarding fluid intake, sleep, and taking rest breaks. Food and Diet Police workers have great risk of being overweight or obese and risk of developing long-term health conditions [ 4 ]. Some of this risk is attributed to poor-quality diet (high in fat, sugar, and salt)—owing to the demands of shift work and the additional occupational stressors associated with police work modifying their relationship with food and unhealthy diet [ 33 ]. Police workers might not be able to plan where they might be at any point in a working day owing to the nature of the job, leading to disparate meals, few or small breakfasts, late mealtimes, and increased caloric intake at night [ 34 ]. This might also encourage them to make lifestyle choices based on whatever is easiest—for example, getting fast food on the go—rather than preparing healthy food in advance. Interestingly, a recent study by Kosmadopolous et al [ 34 ] observed that police officers had great intake of energy from fat and saturated fat during rest days and morning shifts than during evening or night shifts. However, the overall proportions of dietary macronutrients (fat, carbohydrate, and protein) did not significantly differ each day. Kosmadopolous et al [ 34 ] observed a series of dietary patterns that implicated the time at which food was consumed, rather than quantity or composition as the differentiating nutritional factor, which might affect metabolic health during shifts. Working in shifts makes it difficult for police officers and staff to successfully adhere to and sustain healthy lifestyles in the long term. Participants suggested enhanced functionality regarding the ability to view a summary of how changing shifts could have an impact on the consumption of healthy food, and they were also in favor of using only 1 app to monitor all aspects of their health rather than many different ones. There are a number of existing dietary, nutritional, and food information apps available—such as MyFitnessPal [ 35 ]—but none of them successfully align completely with the lifestyle, fluctuating shift patterns, and demands of police work [ 1 , 2 ]. Activity NHS guidelines in the United Kingdom [ 36 ] recommend that people should be performing some type of physical activity every day. Recent studies in this area involving 2 UK police forces have included a physical activity study using wearables, which used a combination of a Fitbit activity monitor and the “Bupa Boost” smartphone app to promote physical activity and reduce sedentary behavior in police officers [ 37 , 38 ]. Specifically targeted apps—focusing on cycling, running, or a combination of both—are not easily configurable for other activities such as swimming, owing to their design architecture. Buckingham et al [ 37 ] noted that there were large individual differences in preferences and perceived impact of the individual and social components of their intervention. These appeared to be owing to personal preferences and personality differences, rather than being associated with any identifiable characteristics, but they highlight how important personalization and tailoring are when considering activity and sedentary behaviors. The study [ 37 ] also emphasized that the targeted user group had accepted mHealth technology and found it extremely useful in improving physical health. Notably, other existing technologies available for use, such as Police Fitness [ 39 ], which prepares individuals to pass the initial job entrance fitness exam or their annual fitness check, only concentrate on a particular aspect of fitness. Moreover, they do not naturally integrate with fluctuating shift patterns. The ability to track any kind of physical activity and to see a summary of the impact of shifts on activity levels was an aspect that participants would particularly like to see in a future iteration. Catch-up cards reminding them to participate in occasional physical activity (according to the scheduled shift) were something they considered would make a difference in their wellness journey. Sleep Among a group of US police officers, it was noted by researchers [ 40 ] that sleep disorders were common and significantly associated with increased risk of self-reported adverse health, performance, and safety outcomes. In a more recent study by Fekedulegn et al [ 41 ], which examined the association of shift work with sleep quality in police officers, the overall prevalence of poor sleep quality was 54%; 44% for the day shift, 60% for the afternoon shift, and 69% for the night shift. The study concluded that night and evening work schedules were associated with elevated prevalence of poor sleep quality among police officers. For participants who worked shifts, maintaining regular sleep patterns was not always possible. Owing to the varied times they needed to go to bed and wake up, participants wanted an app that did not rely on standard workdays and the assumption that they would not be working on weekends and, importantly, also allowed them to integrate other features, such as similarly varying mealtimes when on shift and prompting reminders for relaxation before rest periods [ 15 ]. After testing the app, the participants expressed a desire to see a summary screen to help with understanding the impact of their shifts upon their sleep in helping to maintain overall wellness. For example, by logging sleep patterns and then comparing and contrasting the types of mood after particular shift patterns. Fluid Intake Police officers and staff in frontline roles can sometimes find it difficult to maintain hydration status when on duty. Consequently, the effects of dehydration—fatigue, headaches, and irritability—can lead to loss of productivity while working [ 42 ]. This has led to campaigns to raise awareness such as the Take-a-Sip campaign—launched with funding from Police Care UK [ 42 ]. The NHS guidelines in the United Kingdom [ 43 ] recommend drinking between 6 and 8 glasses of fluid per day. Water; low-fat milk; and sugar-free drinks, including tea and coffee, all count toward this total, highlighting that intake does not necessarily need to be solely focused on water intake, which some existing apps might choose to focus on. Participants mentioned that the goal-setting feature was useful when using it within the fluid intake section. There were suggestions to include this feature in other domains. In the long term, it is intended that, as recommended in the initial study [ 15 ], this feature, once finalized programmatically, is replicated and incorporated into other domains. Good Mental Health In terms of mHealth apps already targeting the mental well-being of police organizations, a UK-based mobile app—Backup Buddy—allows police officers in participating forces to informally view static audio and visual information and signposted support options about common mental health issues [ 44 ]. At the end of 2020, Thrive—a mental health and well-being app—was made available to 3500 officers and staff across West Staffordshire, with it also being made available to friends and family if required [ 45 ]. In addition, in the United Kingdom, the College of Policing recently conducted a randomized controlled trial, giving 1337 police officers in 5 forces access to either Headspace (a mobile mindfulness app) or Mindfit Cop (a web-based mindfulness resource). This study found that both resources improved well-being, life satisfaction, resilience, and performance compared with the control group. The authors concluded that the trial was sufficiently robust to provide evidence of well-being benefits [ 30 ]. A research study is also being conducted by the Police Federation of England and Wales to better understand police officer experiences of using the 87% mental well-being app. This app is designed to support employee well-being strategies [ 46 ]. By adding the good mental health section to the designs, a mood diary and the sleep tracker were made available to users to track personalized elements of mood. Integration of the mood diary with the other sections of the app—such as hours of sleep recorded, exercise performed, skipped or eaten meals, and fluid intake—cross-referenced to individual shift patterns in the future would help to inform and provide users with a chance for reflection and therefore influence behavior change. In the long term, this component also has the potential to align more closely with national support services such as the National Police Wellbeing Service [ 47 , 48 ]. However, positives must be viewed alongside concerns from participants that were highlighted in this phase of testing regarding who would be able to access and make assumptions about the data they added. During testing, we were able to confirm that the data were confidential and that no one had access to personal information. This clarification was made to users to encourage use and allay participant concerns regarding how their managers might monitor and subsequently view some of the data entered. It has been noted that individuals in this profession feel reluctant to ask for help for themselves or to discuss their mental health with others. Historically, the police subculture has consisted of values involving masculinity, independence, and emotional control [ 20 ]. Such values may make it difficult for many police officers and staff to express emotion or seek mental health treatment, which places them at a disadvantage because internalizing their feelings might reflect in work performance [ 20 ]. In such a scenario, it becomes more critical for people in this profession to identify stress early, before it causes additional damage to their mental and physical health. The situation has been exacerbated during and after COVID-19, creating additional uncertainty and increasing the likelihood of stressful situations occurring [ 13 , 14 ]. Financial Well-Being A 2006 study of Taiwanese police officers to assess the quality of life and prevalence of depression in police officers grouped together economic stressors including loans for a house or car, insufficient family income, and debt. According to their results, 52.2% (405/776) of male officers had economic stressors, whereas 30% (17/56) of female officers had economic stressors [ 21 ]. Compared with other professions, police officers and staff have different retirement policies; this means that they retire at a younger age than civilians and have more chance of experiencing negative impacts as they move toward retirement [ 22 ]. An Italian study found that retirees who were financially well-off were less likely to experience declining health when compared with those who were not [ 23 ]. Participants particularly welcomed the inclusion of a financial domain alongside the other aspects of the app, as it gave them good advice and ideas about the pension scheme offered, approaches to saving, and budget planning. Shift Manager Regarding activity, perceived pressure of work and organizational culture appear to be sturdy barriers to reducing sedentary time [ 49 ]. Previous studies have highlighted that there was a sense that high workload had resulted in working through breaks and during personal time becoming the norm [ 50 ]. Police staff has a mandated lawful requirement to take a break in their shift for which they are not paid, whereas police officers are paid for the full shift. This can mean that when operationally necessary, they work through breaks. Police officers in previous studies have expressed a need for more opportunities to take breaks and encouragement from managers or supervisors [ 37 ], as some of our previous participants had also noted [ 15 ]. Overall, 25% (12/48) of the users reported challenges in initially using shift manager. Some responded that they would continue to use their current apps (eg, Google) for managing their shifts, because of the additional functionality offered by other apps. The ability to add personal notes to the shift manager and to share their weekly or monthly shift pattern with family members was something that users would like to see in an improved iteration. Having these features would cover users who preferred to use something different at the moment. This feature has become the key central cog that other elements can be integrated with—for example, working in conjunction with the catch-up card function—therefore, the design and use of this function must be simple, effective, and easy to visualize and track. Feedback resulted in the early diary design to input shift being modified and renamed. Currently, there are 6 core shift patterns that have been prepopulated in the app, which users can choose to select. The frequency of catch-up cards was also set according to the shift chosen and included upon client feedback. The ability to view the effect of different factors (food, activity, fluid intake, and sleep) on overall wellness—in conjunction with shift—will prompt police staff and officers to make lifestyle modifications to improve health. Feedback received from users also provided insights to the developers to improve the shift manager feature and to add a help section to educate beginners about how to add and edit their shift patterns. Goal Setting and Catch-Up Cards Behavior change is likely to play a large role in making an app focusing on health and well-being successful, with the suggestion that increased implementation of behavior change techniques could improve interventions and achieve high levels of user engagement [ 51 ]. The goal-setting feature was appreciated by participants when using it within the fluid intake section, and the intention is, once finalized, to integrate this functionality within other domains of the app. Occupational stress is the main contributor to the risk of police officers and staff developing obesity and increasing the risk of long-term health conditions such as cardiovascular and metabolic diseases. To control this, it is very important to self-manage sleep patterns, take regular breaks, monitor dietary and food habits, regulate water intake, help with smoking cessation, and reduce alcohol consumption. Referring to the study conducted by Voyer [ 52 ], nudging offers a choice pattern to users that can make changes in their behavior and how decisions are taken at a personal level to improve health. Therefore, it is considered as a behavioral economic concept in the new world. The study by Kwan et al [ 53 ] highlighted that reminding the patient to maintain good habits by sending nudges has the potential to reduce the cost of health care and help patients take long-term control of their health. Self-management empowers users to make decisions in favor of their health, and nudges or reminders keep them more involved and informed in maintaining their health. Nudge theory is a young behavioral economic concept that “influences the behaviour and decision-making of patients through choice architecture” [ 52 ]. Nudging is not mandatory; rather, it gives small choices in behavior, at a level that has the potential to influence. In the initial research requirement gathering, participants mentioned that notifications on the app would help them to perform tasks that they generally forgot, as they did not access the app many times during the day [ 15 ]. Catch-up cards were introduced and linked to the shift manager in this version of the app to support and encourage police officers and staff to try and maintain good habits. Catch-up cards are scheduled differently for each shift pattern and rest day to prepare the participants for their next shift. They work as a “nudge” or reminder for the participants to do breathing exercises, sleep on time, complete activity steps, and so on. Supplementary Information and Guidance Previously, some pilot research work was undertaken with project team members on an app to centralize evidence-based nutrition and lifestyle guidance for health care professionals and people living beyond cancer—enabling them to obtain guidance and information and create and track nutrition and activity-related goals [ 54 ]. The research work also fed useful reflections into the design of this project. Each domain in the app that requires input from the users has an information section that gives recommendations about how much fluid to take, what the healthy options are, and so on, according to NHS guidelines. Participants found this guiding information to be helpful, as it was easy to refer to in case of query. However, in this study, there were few suggestions received around improving the design to draw more attention to these particular sections. Limitations Although the authors believe that the results from this study can be generalized to other police forces across the country, we acknowledge that there is a limitation of only accessing data from a subsection of 1 regional UK police force, which might have inherent organizational biases toward health and well-being. However, this approach can be expanded to cover more regions in due course. Regarding bias with purposeful sampling—where the belief is that qualitative research should be describing the medium or the norm—the point to underline is that new phenomena are being described; therefore, we needed to purposively select the best examples of what we were interested in. This gave us the clearest cases with the least “noise” or extraneous errors and allowed for the identification of characteristics and boundaries [ 55 ]. A further limitation of the study was the greater number of responses from women (32/48, 67%) than those from men when compared with regional UK police workforce numbers as of March 2022, which noted that the gender split was 48% women and 52% men [ 56 ]. Future Studies The wellness app for the commissioning force has now been subsequently soft launched with funding for the bespoke pattern design agreed upon. The findings from this study are being shared with the developers to analyze the possibilities of implementing them in the next release of the app and have the improved version of the app trialed before its final launch for a wide police population. Organizational Support In addition to a well-designed mobile app, suitable scaffolded organizational support implemented alongside the eventual release of the app, together with an evaluation of how the app is being used, offers the best chance of producing positive results. This could include encouraging the use of more health-oriented leadership—a style of leadership associated with more well-being and low levels of burnout, depression, and physical complaints among police officers [ 57 ]. Voice Integration Emergent technological enhancements (such as Google Voice and Google Assistant) offer opportunities for improved personalized eHealth solutions [ 58 ] and increased engagement [ 59 ] and adherence [ 60 ]. In the area of nutrition, projects are already being conducted, such as the design, development, and evaluation of an Alexa Skill on food and nutrition management for native American patients with diabetes [ 61 ]. Similarly, regarding fitness, TandemTrack combines a mobile app and an Alexa skill to support exercise regimens, data capture, feedback, and reminders [ 62 ]. Members of this team have previously explored the tentative use of voice-activated speakers or assistants such as Google’s Assistant or Amazon’s Alexa to enable the input of information via voice rather than keyboard [ 63 ], which might also assist in making this type of innovation quick to use and therefore more user-friendly. Investigating Other ESP Pathways These unique issues, the continuing long-term effects of the pandemic on employee health and well-being, and the highlighted gaps in solutions available at present are not only applicable to police staff and officers but also to other ESP—such as firefighters [ 64 , 65 ], paramedics [ 66 , 67 ], and health care professionals [ 68 , 69 ]—and other shift workers. Therefore, the project team is seeking further funding, to explore the development and expansion of this approach to health and well-being issues in other sectors, in addition to the police. Conclusions This study highlights the importance of coparticipation with officers and staff across the entire development cycle, to coproduce a human-centered design methodology to enable the development of a considered and user-centered solution. It demonstrates the need for producing a multifunctional tool rather than focusing purely on an individual element for this user group. It also highlights how linking and being able to track optional, personalized elements of health data against each other, cross-referenced to individual shift patterns, might help to inform and provide users with a chance for reflection and therefore influence behavior change. Acknowledgments The authors would like to thank all the participants of the web-based survey and interviews. This research project was cofunded by Bournemouth University and the commissioning client. Authors' Contributions JM, FB, and HD conceived and designed the study. RM conducted the participant interviews and data analysis. 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