Preadolescent Students’ Engagement With an mHealth Intervention Fostering Social Comparison for Health Behavior Change: Crossover Experimental Study
Authors: Nuijten Raoul Ceasar Yannic , Van Gorp Pieter , Borghouts Tom , Le Blanc Pascale , Van den Berg Pauline , Kemperman Astrid , Hadian Ehsan , Simons Monique 
Published: May 2021

Background
Contemporary mobile health (mHealth) interventions use various behavior change techniques to promote healthier lifestyles. Social comparison is one of the techniques that is consensually agreed to be effective in engaging the general population in mHealth interventions. However, it is unclear how this strategy can be best used to engage preadolescents. Nevertheless, this strategy has great potential for this target audience, as they are particularly developing their social skills.

Objective
This study aims to evaluate how social comparison drives preadolescents’ engagement with an mHealth app.

Methods
We designed a 12-week crossover experiment in which we studied 3 approaches to implementing behavior change via social comparison. This study was hosted in a school environment to leverage naturally existing social structures among preadolescents. During the experiment, students and teachers used an mHealth tool that awarded points for performing healthy activities. Participants could read their aggregated scores on a leaderboard and compare their performance with others. In particular, these leaderboards were tweaked to implement 3 approaches of the social comparison technique. The first approach focused on intragroup comparison (ie, students and teachers competing against each other to obtain the most points), whereas the other two approaches focused on intergroup comparison (ie, classes of students and their mentoring teachers collaborating to compete against other classes). Additionally, in the third approach, the performance of teachers was highlighted to further increase students’ engagement through teachers’ natural exemplary function. To obtain our results, we used linear modeling techniques to analyze the dropout rates and engagement levels for the different approaches. In such analyses, we also considered individual participant traits.

Results
Our sample included 313 participants—290 students (92.7%) and 23 teachers (7.3%). It was found that student engagement levels dropped over time and declined during holidays. However, students seemed to monitor the intergroup competitions more closely than the intragroup competitions, as they, on average, checked the mHealth app more often when they were engaged in team-based comparisons. Students, on average, performed the most unique activities when they were engaged in the second intergroup setting, perhaps because their teachers were most active in this setting. Moreover, teachers seemed to play an important role in engaging their students, as their relationship with their students influenced the engagement of the students.

Conclusions
When using social comparison to engage preadolescents with an mHealth tool, an intergroup setting, rather than an intragroup competition, motivated them to engage with the app but did not necessarily motivate them to perform more activities. It seems that the number of unique activities that preadolescents perform depends on the activeness of a role model. Moreover, this effect is amplified by preadolescents’ perceptions of closeness to that role model.