Most adults do not engage in sufficient physical activity to maintain good health. Smartphone apps are increasingly used to support physical activity but typically focus on tracking behaviors with no support for the complex process of behavior change. Tracking features do not engage all users, and apps could better reach their targets by engaging users in reflecting their reasons, capabilities, and opportunities to change. Motivational interviewing supports this active engagement in self-reflection and self-regulation by fostering psychological needs proposed by the self-determination theory . However, it is unknown whether digitalized motivational interviewing in a smartphone app engages users in this process.This study aimed to describe the theory- and evidence-based development of the Precious app and to examine how digitalized motivational interviewing using a smartphone app engages users in the behavior change process. Specifically, we aimed to determine if use of the Precious app elicits change talk in participants and how they perceive autonomy support in the app.A multidisciplinary team built the Precious app to support engagement in the behavior change process. The Precious app targets reflective processes with motivational interviewing and spontaneous processes with gamified tools, and builds on the principles of self-determination theory and control theory by using 7 relational techniques and 12 behavior change techniques. The feasibility of the app was tested among 12 adults, who were asked to interact with the prototype and think aloud. Semistructured interviews allowed participants to extend their statements. Participants’ interactions with the app were video recorded, transcribed, and analyzed with deductive thematic analysis to identify the theoretical themes related to autonomy support and change talk.Participants valued the autonomy supportive features in the Precious app . We identified the following five themes based on the theory-based theme autonomy support: valuing the chance to choose, concern about lack of autonomy, expecting controlling features, autonomous goals, and autonomy supportive feedback. The motivational interviewing features actively engaged participants in reflecting their outcome goals and reasons for activity, producing several types of change talk and very little sustain talk. The types of change talk identified were desire, need, reasons, ability, commitment, and taking steps toward change.The Precious app takes a unique approach to engage users in the behavior change process by targeting both reflective and spontaneous processes. It allows motivational interviewing in a mobile form, supports psychological needs with relational techniques, and targets intrinsic motivation with gamified elements. The motivational interviewing approach shows promise, but the impact of its interactive features and tailored feedback needs to be studied over time. The Precious app is undergoing testing in a series of n-of-1 randomized controlled trials. Lifestyle-related diseases, such as cardiovascular diseases, type 2 diabetes, and cancers, lead to a decrease in quality of life and are the leading causes for years of life lost worldwide . StretchAs a consequence, hundreds of thousands of smartphone health apps have emerged for tracking physical activity. With their interactive features, onboard sensors, and associated wearables, smartphones are a natural tool for tracking and self-monitoring activity ,5. IndivTracking physical activity is indeed a key element of many successful physical activity interventions. Self-regulatory behavior change techniques (BCTs)  related Smartphone apps have shown promise in reducing sedentary behaviors ,16, but summative engagement, the quantitative metrics of usage time and frequency, is not enough for understanding neither the user experience in the moment-to-moment interaction with the app nor how apps support active involvement in the behavior change process and the intervention goals . Th. Th79]. In addition to the gamified features of the Mountain Climber self-regulation tool, other components were also envisaged to help foster intrinsic motivation for using the Precious app . These cSwiping left in the main menu reveals the user their journey, a map of achievements. Completing the motivational tasks and activity challenges creates a badge on a background of changing landscapes. All actions accumulate points, with less points obtained from app use and more points, from sustained streaks in physical activity. Journey’s main function is to increase the sense of competence and self-efficacy by showing visible cues of progress and listing all the actions taken on the way to an active life. The changing landscape may motivate users to complete actions to progress into new levels .A location-based activity game was designed to create entertaining challenges, tasks, and competition that would make walking intrinsically enjoyable. The aim of the game is to conquer areas on the map by walking around them and by collaborating and competing with other app users. This addresses the psychological needs of relatedness and adds an element of excitement and fun for those who enjoy competition ,81. UserThe purpose of the self-regulation tool is to give users a clear picture of their current activity level and how that compares with their target level  are not accurately recorded by wrist-worn accelerometers, users can also manually log their activities. The Mountain climber tool allows users to select a physical activity from a list and to specify the time and intensity of this activity. Knowing a user’s height and weight, the Precious app converts the activity to steps using metabolic equivalent (MET) values and the following equation ,86:Steps/minute for activity = /3.5As a final source of physical activity data, the Precious app used data collected from the phone’s onboard accelerometer and the Google Play Services Fitness application programming interface (API). This allowed for identification of steps taken as well as minutes spent walking, running, cycling, traveling in a vehicle or being sedentary. This source of physical activity data was used in periods where the app was unable to communicate with the activity bracelet, and no physical activities had been manually entered.When amalgamating data from various sources, users’ manually entered activities were given the highest priority. Any step counts received from the Mi Band or onboard accelerometer that had timestamps that overlapped with the timestamps of manually entered activities were not added to an individual’s total. Steps obtained from the Mi Band were given the second highest priority. Steps obtained from Google Play Services Fitness API were given the lowest priority and were only added to an individual’s total in periods in which the Mi Band had not recorded any new step count activity. The aggregation of these three data sources was presented to users in real time, which offers users a comprehensive and realistic picture of how their steps accumulate during the day, how different activities contribute to the whole activity, and how their activity varies daily.The interviewers recruited a convenience sample of 12 adults living in two different Finnish regions, with diverse educational backgrounds  and ages ranging from 25 to 63 years. Of 12 participants, 8 were women and 4 were men, both genders ranging from physically inactive to highly active. Participants had different levels of experience with smartphone apps, ranging from active sport app users to participants without a smartphone. With think-aloud studies, five participants are deemed sufficient for detecting most usability problems ,88. To aOverall, two participants (P6 and P7) agreed to participate only in a think-aloud study of the biofeedback report and were thus excluded from the current analyses  until they were speaking continuously, describing everything they saw, thought, or did with the app . ParticiTo assess participants’ physical activity levels, we used a validated single-item question, “On a typical week, on how many days do you do a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate. This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places but should not include housework or physical activity that may be part of your job” .Think-aloud walkthrough interviews were followed by a semistructured interview with open-ended questions on participants’ previous experience with mobile apps, general perceptions of the Precious app and its most/least useful features, suggestions for improvement and usage, possible features that could exclude potential users, and factors related to engagement with the service. These questions were mainly used for the technical usability analyses not presented in this study. Interviews and think-aloud walk-throughs as well as participants’ on-screen interactions with the app were video recorded. Interview recordings were transcribed verbatim by a research assistant and a trainee. User actions such as tapping and swiping the screen were also transcribed, as the analysis of user engagement included all interactions with the app.Transcripts for each participant from think-aloud and semistructured interviews were analyzed with a deductive, theory-based thematic analysis, informed by Braun and Clarke’s phases of thematic analysis , used prThe theory-driven RQs on change talk  and autonomy support (self-determination theory) were analyzed with a deductive approach, aiming to identify any passages that fit these theoretically defined constructs . Change The feasibility analysis on participants’ engagement with the Precious app answered the following two RQs: (1) how participants discussed autonomy support during the think-aloud walkthrough and the end interview and (2) what kind of change talk did the Precious app elicit in the users during the walk-throughs.autonomy support: valuing the chance to choose, autonomy supportive feedback, expecting controlling features, concern about lack of autonomy, and autonomous goals.We identified the following themes around the original, theory-based theme Consistent with the self-determination theory, participants valued autonomy supportive features, especially the chance to personalize the content and make selections:It is good that this background information is added there so that it’s not like the same for everyone. Absolutely, it’s good to have it, so that you can influence it yourself.P8The chance to choose was especially relevant for the self-regulation features, as participants appreciated the possibility to adjust the daily step goal and consider the day ahead:So, every day you can set the goal. But that sounds smart. Maybe a bit smarter than what I have in use, where there’s for every day that...I think it has 10 000 the...Or you can’t set a goal, they think that 10 000 is the recommendation...I think this is smarter that you can also...if, like, you know that this day will be...that maybe there’s not so much walking, so...P4A participant with low levels of activity thought she would take advantage of the ability to set personal step goals to make sure she would achieve them:I guess I’d probably put, if you could put, beforehand the goals, so, I’d probably put so… maybe even lower? So that they would be really, like, achievable and probably I would achieve them.P11The number of personalization options was generally found to be reasonable, and users found options that pleased them. However, overall, two participants felt that the list of 20 outcome goals had too many options to choose from:I: What are you thinking?P9: Just that there’s a lot of options again, there was four a moment ago and now there’s like forty...already reading these, now that it’s a busy situation...well at least, I’ll tick some of these.P5: [chooses Feel more healthy] Yeah, there were too many. And again, you can choose so many different ones.When asked if the service would exclude any user groups, one participant saw the number of options as too high for elderly people:Then if the idea was that this is for elderly people, then it might be a problem that there’s so much of everything. This might be like a shock, or at least I remember when I’ve tried to teach my grand-parents Internet and computer use, and just when you open the screen and there’s a lot of small icons, it’s often very difficult. And when you need to click and...really self-evident stuff can become a threshold, but I don’t know for how difficult population you are aiming this.P10In addition to freedom of choice and tailoring, participants wished to receive encouragement and praise and mentioned that the tone of interaction is important:Although [another sport app] it’s just an app, but it says something like “now you’ve missed your training session,” it makes me feel somehow bad. So probably you should pay attention to that, how the feedback is.P4The interviews revealed that participants were used to apps that prescribed specific goals or activities. They assumed that the app would tell them, for instance, how much activity they are expected to do:P12: Here it’s like 36 percent. 36% of what? Like...I: Yeah, that’s not clear?P12:Taps 36% circle. Nothing happensP12: Probably like how much should I walk or something.These expectations were based on their previous experiences with apps that provided less autonomy support:This is slightly different than what I’ve previously used of thesehealth apps. Usually, very first question is height and weight and target weight. That’s the most common. But well, this seems good...or like good so that it’s not always necessarily the weight loss. That usually those apps have weight loss as default...P4lack of autonomy, for instance, that their early choices would tunnel them into unwanted recommendations later:In addition to expecting health apps to be controlling, participants also expressed concern about this And then, choosing “stay healthy” brings to my mind immediately that now [Precious] will suggest to “take long walks” and “do yoga” and all these healthy activities, while I don’t like that at all. So, it instantly brings to my mind those stereotypes that this kind of healthy activity includes. Which you might not want yourself- although I choose this “Stay healthy,” I think however if I should have put some “Face challenges” so that I will get some fun to the activity.P9How is it programmed then [to provide suggestions]...Does it affect a lot if you choose the wrong one of the twogoals].... “Functional abilities,” that is also a good thing. [Selects “Maintain my functional ability”]. P10need type of change talk, mainly when reflecting on which outcome goal options would be most relevant for them:Participants also actively expressed P9: [selects “Improve my general mood”] This is just what I need, to get out for a run or to be alone. - -P9: Health is the most important. [Chooses the option “Maintain my functional ability” and “Stay healthy”] [chooses Physical activity as the behavioral strategy]. talk consisted partly of the selections they made. We call this implicit change talk:Although all participants engaged in the selection process and found four options that were suitable for them, not all of them actively voiced aloud the rationales behind their choices. Their [Opens What do I want? tool] Hmm. So, I can put only one or then maximum four options here. [Selects “become more flexible” as an outcome goal] Okay, this is good. I become less...okay that’s it. Hmm. P12Presenting possible outcome goals as a list may not only be a positive resource for users. A couple of participants voiced sustain talk when arguing against a decision to choose certain outcome goals:P9: I am very stiff, I should probably put that [“feel more flexible”] but I don’t really care about being stiff.  [Chooses “Increase my stamina”] I: So, you took into account that it asks what you wantP9: Yeah...Probably it would be good to be a bit more flexible...And I should lose some weight but that’s not such a top thing for me...Would it be good to choose four?I: Yeah, is it unclear whether you need to choose?P9: No, it isn’t, no you don’t need to but...Well, there are that kind of options that I could choose from.Chooses the option “Relieve stress or tension”P9: Health is the most important. [Chooses the options “Maintain my functional ability” and “Stay healthy”]. needs in relation to their current life situation:Participants reflected their actual The program asks, which of these [outcome goals] is most important, but it’s hard to give weight to one or the other.. On different moments, different things are important, but it asks what would be most important right now...Removing stress [selects “Relieve stress or tension”]. .P3Sometimes participants did not express change talk spontaneously, but they appeared to have thought about the responses when asked:P3: So, let’s see what is in there...So the program wants to find out what I really want, and...now I’m thinking what it asked.I: So, what are you thinking?P3: So, sharing happy moments, adventures, being in the nature, doing successful things. .All participants were happy to select a number describing their perception of the importance of physical activity, but as the app did not require text input, they swiped through the pages at a relatively fast pace. Only a few participants reflected aloud their choices spontaneously, but almost all provided reasons for the importance of physical activity when asked what they were thinking. We identified the themes desire, need, reason, and sustain talk from interactions with the importance ruler:P1:moves the pointer from 7 to 4I: So, tell now, like, what you think or see?P1:moves the pointer from 4 to 7 and from 7 to 8P1: I think that [physical activity] is importantI: Mm?P1: Do I need to think about something else? [swipes forward] I guess not. I’ve been thinking for a second.swipes forwardP1: Because of course I wanted to be more active. . Yeah, that’s alright. P3: That it [physical activity] just keeps me active. It makes me feel healthy. So, in this question “physical activity would most help me to...” I would answer the button that was already selected, that it relieves stress and tension. P9: So, I would want to choose immediately all of them [four user’s favorite outcome goals displayed], maybe least this “have fun”? Although it’s [physical activity is] very important to me and it’s fun for me.But still, I’d see that if you need to think of health, then all these three others. Some participants chose the number by comparing themselves to their peers. Participant 9 had observed how the lack of activity has a different impact on her than on others:Well...I don’t know, I just find [physical activity] fun. It is important to me to stay in good shape so that I have energy to do things in life and so on. Also, maybe I compare myself to other people. Like, how important [physical activity] is to me compared to my pals. They don’t care if they can’t go for a run every now and then or if they move, but I become a bag of nerves. It starts to feel like you get mad from everything  so, that kind of thoughts.P9sustain talk:Participant 8 saw himself as a less active person than his wife, which affected his selections and elicited some When I think of my wife when she always says that she will feel bad if she can’t go for a run, well, I am not at all like that. P8Confidence ruler tool asks about participants’ confidence to be physically active and offers options to increase the confidence P10need to increase activity:An inactive participant expressed a I guess...I am not that active, so I feel like there’s much to improve. P11Confidence ruler, participant 10 mentioned that a detailed plan might help him increase physical activity.While exploring the suggested BCTs in the Ok, now this asks what would help me in this...Again, this suggests remembering...So, it’s kind of asking me these, ok...I wonder if it has automatically chosen me that one or if I have accidentally touched it myself. Some accurate plan could maybe [help me to increase physical activity] [selects the option Having a detailed activity plan] .P10What’s next? Tool assesses users’ current levels of physical activity and intentions to be active to tailor further suggestions. The two participants testing the tool actively engaged, making the selections that were relevant for them. An inactive user expressed the desire to increase activity:The  Well I absolutely would want! [selects “I definitely want to be more active”]. P11A physically active user did not see a need to increase his activity levels and, understandably, expressed sustain talk and ambivalence:This here thinks I’d need to change the level of physical activity, I personally thought about it more like...that it’s just one central aspect...I didn’t see I would somehow need to change it. ...Let’s say that I have an ambivalent feeling, do I want to be more physically active. P10The Time machine tool suggested imagination tasks of pleasurable physical activity in the past or in the future. It was tested by only two users, and no change talk was coded from their interviews.needs- and reasons-based change talk while using the motivational interviewing features, the change talk produced by the Mountain climber tool was commitment to the behavior change process and taking steps toward change. Participants used different Precious app tools in a random order, so this difference does not reflect the time spent using the app.As opposed to the Participants saw the logging tool as a learning instrument and logging future activities as a commitment that might help them reach their goals. Participant 11 describes how she would learn about her activity levels while using the logging tool and could then increase her step goals:Yes I believe I could even go and do [the planning], and I find it nice that I could add the goals for the next day, and then in the evening, add how I moved that day and then see whether it happened, and then add for the next day...then I would know if the goals were low but I moved much more, the steps just appear, just like that, then for the next day I could put a bit higher. P11Participant 12 realized that adding the activity in the Precious app makes it more likely that she will do the activity the next day:P12:Selects an activityP12: If I already do it [the logging] now, then I have to go there tomorrow in the morning. That’s actually quite good. Self-regulation features also received some criticism. Participant 9 expressed sustain change talk on self-regulation, as he thought he is not organized enough to do planning:I: The meaning is that it could be used for planning, do you think it would work like that?P9: Ooh, not me at least, I’m so bad at planning anything in advance that I wouldn’t... Maybe it could? Maybe it could be used as such. Certainly, if I were a bit more organized person. This study presented the development and feasibility testing of the Precious app, which aims to engage users in the behavior change process with relational techniques from motivational interviewing and gamified self-regulation. The feasibility study found that interaction with digitalized motivational interviewing features helped participants reflect their personally valuable goals, needs, desires, and reasons for physical activity. Autonomy supporting features were typically found to be important, although some participants criticized the number of available options and some expressed concerns about being profiled and possibly receiving the wrong types of suggestions. In this section, we will discuss the theoretical framework behind the Precious app and the results of the feasibility study on user engagement in behavior change.We developed the Precious app using a theoretical framework , which hDigitalized motivational interviewing for physical activity has not been previously implemented for smartphones , althougThe Precious app’s digitalized motivational interviewing features were implemented as seven question-based tools using seven relational techniques. These relational and motivational features were hypothesized to increase users’ engagement in the behavior change process by increasing relatedness to the app and facilitating self-reflection and the use of self-regulatory BCTs , which cConquer the city feature or keeping daily steps up to create a panorama of high mountains with the Mountain climber tool.High intrinsic motivation is the best predictor of sustained physical activity , but notMountain climber tool that uses gamification principles to increase intrinsic motivation for BCT use. The self-regulatory BCTs included daily physical activity goal setting, reviewing behavioral goals, making action plans, self-monitoring, receiving feedback on behavior, perceiving the discrepancy between the current behavior and goal, and prompts to complete the daily step goal. These self-regulatory BCTs have been found to increase both physical activity [Control theory–related self-regulatory BCTs were implemented as a activity  and motiactivity , and theThe feasibility analysis of participants’ engagement with the Precious app addressed the following questions: (1) How did participants discuss autonomy support? and (2) what kind of change talk did the Precious app elicit in the users?In line with the self-determination theory, participants valued the autonomy supportive features, such as the tailoring of goals, behaviors, and activities, instead of an externally set behavioral target, as seen in previous Web-based interventions ,96. The What’s next? tool of the Precious app.As the Precious app was designed around a list of preselected answer options, it could not offer a complete freedom of choice to the users. A digital service needs to find a balance of the freedom given to the user and the amount of content that can be tailored to users’ wishes. The more determined the answer options are, the more tailored suggestions can be offered to those specific choices. The more freedom the user has in indicating their preferences, the higher is the risk that the app content will not meet those wishes. It is also not known how accurately users want their ideas to be mirrored. Simply rephrasing users’ preferences may not be optimally engaging: One study found an app more engaging when it included recommendations for people resembling the user, instead of recommendations based on personal history only . One optdesire, reason, and need, when using the motivational interviewing features, and commitment and taking steps toward change, when using the Mountain climber tool. Considering participants’ varying levels of motivation and activity, it is promising that change talk was identified across the full sample. There were very few occasions of sustain talk and ambivalence. This may be a positive indicator about the ability of the Precious app to evoke positive cognitions about physical activity. The Precious app, however, has limited means for exploring possible negative elements related to increased physical activity or positive aspects of maintaining inactivity, which are often identified in face-to-face counseling [Participants engaged actively with the app during the think-aloud interviews, making selections and reflecting their choices in relation to their values and current life situation. They expressed a wide range of change talk: mainly unseling . One optunseling ,74.Time machine tool for using mental rehearsal of past and future behavior did not elicit change talk during use. As the tool was tested by only two users, it is too early to conclude that this tool would not support other participants. On the basis of a fast pace with which participants advanced through all the Precious app features, more structured guidance  may work better on a smartphone platform than a list of open questions and imagination tasks.Surprisingly, the implicit change talk. The CLEAR coding system, used for recognizing change talk [Confidence rulers, change talk should only be coded if the participant provides a verbal qualifier for the number. At the first stages of analysis, we aimed to extend this principle to all the interactions with the Precious app, analyzing only clear oral statements. Soon, we discovered that participants’ selections were so embedded in the discourse that including interactions with the service was indispensable to get an accurate picture of the participants’ thought processes.Analyses of the think-aloud walk-throughs underlined how making selections while using the app is part of the discourse on change or a form of nge talk , suggestimplicit change talk  may differ from change talk that is elicited verbally in interactions with a coach or counselor. Miller and Rollnick [The Rollnick  point ouOffering a service with relational elements and tailored feedback may exceed the impact of simply writing down an answer, but it is possible that the relatedness experienced with the service moderates this effect so that the more strongly the user feels an app is an active, responsive body in the interaction, the stronger the impact of the intervention is. The more autonomous and interactive digital services become, the more users may feel responsible for and committed to the actions negotiated with them. Getting users to select answers on their personal choices, values, and achievements may also increase their engagement with the app via activating users’ representations of their identity and self-image. In gaming research, players have experienced digital games to be most intrinsically motivating when their gaming experiences have been congruent with their ideal selves .The think-aloud interviews only assessed a brief (30-60 min) use of the Precious app features. Participants did not have the chance to see how their physical activity accumulates over time or how the app’s feedback messages depend on their goal progress. Thus, the interview only provided information on participants’ initial reactions to the app’s motivational and self-regulatory features. For this reason, despite studying perceived autonomy support, the interviews did not address the two other basic needs of the self-determination theory , as we hypothesized these to increase through regular use of the app, with the rules engine providing encouragement and feedback on behavior. Similarly, the gamified elements can only be studied after extended use in the natural environment.What’s next?, Time machine, and Confidence ruler were tested by only two participants because of late implementation. As is typical for pilot studies [The features of the Precious app were still being developed through the feasibility interview phase, meaning that some features were available for the last interviewees only.  studies , the samReview behavior goal(s) jointly with the person [jointly if it is suggested by a digital tool or a chatbot and is a digital service with relational elements able to provide Social rewards? [Interaction with technology needs further focus on the behavioral sciences. Despite the relational nature of motivational interviewing, studies offering digital motivational interviewing features rarely discuss how accurately it can be delivered with technology and how complexities related to digitalization of motivational interviewing might be addressed . Currente person , is the rewards? . These qThe current implementation of the app is mostly text based. Several elements of gamification could be taken further, for instance, the Time machine tool offers a rich platform for visual elements that would enhance the user experience . HoweverThis paper described the development and feasibility testing of the Precious app. We suggested that an app can support engagement in the behavior change process through two pathways: encouraging active reflection of users’ motivations, capabilities, and opportunities for physical activity and providing gamified elements with challenges and fun. Both pathways can satisfy users’ psychological needs of autonomy, competence, and relatedness, increase their autonomous motivation, and support their self-regulation.The novelty of the Precious app is in providing relational support and addressing both reflective and spontaneous ways of motivating users. The Precious app aims to support an active cognitive engagement with the behavior change process using reflection tasks. The app builds relatedness with relational techniques from motivational interviewing and by supporting basic psychological needs described in the self-determination theory. Gamification elements include the self-regulation tool, which helps users to set goals, make plans, and monitor their progress with a mountain visualization. To collect and present physical activity data accurately, the app aggregates data from several sources: activity bracelets, smartphone sensors, and self-reports. The app consists of independent tools that can be switched on and off, enabling tailoring of personalized suggestions and testing specific intervention elements in a controlled way.The feasibility interviews of the digitalized motivational interviewing features revealed that participants value personalization options, but the app also needs to clearly communicate how the information collected from users will be used for recommendations and tailoring and which choices users are able to change later. During the think-aloud interviews, motivational app features elicited change talk on needs, reasons, and desires to change, whereas self-regulatory features elicited commitment and taking steps toward change types of change talk. This active engagement in self-reflection can be perceived as a proxy for engagement in the first steps of the behavior change process. The fast pace with which users typically advanced through the app suggests that smartphone-based interventions may benefit from interactive functions instead of open questions and imagination tasks.Apps supporting behavior change need to engage users in the behavior change process. Feasibility tests with the Precious app suggest that this can be done by addressing users’ psychological needs and by supporting active self-reflection. The impact of specific intervention elements on individuals’ self-regulation and daily physical activity over time will be tested in a series of N-of-1 field studies .


Despite the accumulating evidence on the role of professional helping relationships for highly disadvantaged populations, methodological shortcomings have made it difficult to establish a robust relationships-outcomes link. This study sought to establish the impact of professional helping relationships on the trajectories over 24 months of housing stability for 2141 people facing severe and multiple disadvantage using data from the Housing First controlled trial in Canada.The study used a mixed method design. Latent growth curve and growth mixture models assessed the impact of working alliance across the sample as a whole and within subgroups with different patterns of housing stability. Thematic analysis explored the factors that may affect the quality of working alliances within different subgroups.Three distinct trajectories of housing stability emerged  with professional helping relationships having different effects in each. The analysis revealed structural and individual circumstances that may explain differences among the classes.The findings underscore the role of professional helping relationships, as distinct from services, in major interventions for highly disadvantaged populations, and draws new attention to the temporal patterns of responses to both the quality of relationship and targeted interventions. There is good evidence that the provision of housing can alter the trajectories of people facing severe and multiple disadvantages, particularly those experiencing homelessness. Interventions like Housing First have been shown repeatedly to reduce homelessness, increase housing stability, decrease hospitalisation, and improve quality of life –6. HowevMorse’s review  highlighThere is other evidence that the worker-client relationship can influence outcomes. Goering, Wasylenki, Lindsay, Lemire, and Rhodes , for insSeveral methodological limitations need to be noted, however . For insA mixed method design was used. The study’s first two aims were assessed via quantitative analyses whereas qualitative analysis was used to explore the third aim to complement the quantitative analyses.What is the impact of the working alliance on trajectories of housing stability among homeless people, controlling for age, gender, intervention, and adverse childhood experiences? In line with other research –22, it wAre there multiple trajectories of housing stability among homeless people? As in previous studies , 27, a vHow does working alliance affects subgroups of people experiencing homelessness? In light of research underscoring the role of client and systemic factors in the development of relationships, for example substance abuse or access to independent housing, it was expected that working alliance would affect different subgroups differently.Three research questions were explored:n = 195; 119 HF, 76 TAU) from the larger clinical trial. Sub-sample selection was conducted as follows. For the initial interviews, one out of every 10 participants per study condition for each site was selected by the site researchers, shifting gradually to a more purposeful selection  to ensure representativeness of the sub-sample when compared to the larger sample at each site. Comparisons of the baseline sub-sample with the larger sample on more than 50 demographic, clinical diagnostic, and outcome measures revealed significant differences on three of these variables  ; CFI = .629; TLI = .588). A quadratic growth trajectory was better, reaching acceptable fit . The RMSEA tends not to perform well with growth curve models because of the few degrees of freedom  you know, I can call her and there’s times where I have really needed her and she like drove to my place and [Awesome] or gave me rides to appointments, she’s an amazing worker. .Very much so, it’s probably one of the, one of the most, most reasons why I am still where I am at because of them and the support [Um hmm] you know what I mean, [Yeah] if that makes any sense. […] Um hmm, and real support, not just phony going through the motions shit. .She [worker] was in my space, she just kept coming to my door and I’m sick of them you know, they pay attention to ya if you flood or burn the house down. But not otherwise, not. .My old [worker] um closed my file while I, while I was still on uh probation, and told me that I didn’t have enough goals to work on yet. .sharp rise, sustained and decline housing class).I just need somebody and she tells me she’s not qualified and that’s it. I usually just don’t answer the door, I peek out and see who it is, and I don’t answer the door. Because why would I want to repeat the same story to a different person. .My new family now. I’m gonna miss it once it’s finished you know. .I have accumulated a lot of stuff from my apartment, a lot of nice stuff and I love my apartment and it’s going to be {Long pause} hard leaving it if they don’t get more funding after the 3 years.  compared to the sharp rise, sustained and decline housing class (41%), decreasing the chances of them being connected to a worker (See Table hardly anytime housed class).Like, I’d feel like I was getting support in one area and [I would wonder] God, how long is it going to last? You know, I had different people that I’d see on a regular basis, but people were always passing the buck. And it got to the point for me where it didn’t matter who I was talking to – I didn’t feel that I was getting the right answers. I would feel like I was spinning my wheels. .No contact with family? They’re all dead. My sister I haven’t seen in 25 years and that’s about it. .A lot of my friends are disabled and just can’t hold the alcohol and my family members we’re distant. I talk to them once a year. .When I left (Place08), I had to go before I lost it and put myself into jail for a longer period of time, so I had to leave the building. I was only in there from February to June. That’s as much as I could take of it. .Well when I went into the (Place03) I had 6 months clean. I managed to stay 2 months clean doing the laundry there... And then the building started filling up, and it was filling up with all the worst druggies – the people that really were un-housable anywhere else. And they started knocking on my door asking for lighters at three o’clock in the morning, offering me tokes... I mean, it was just beyond... It’s like, they could see I was straight and they liked that, but they wanted to bring me down. So, I had a lot of people offering me drugs and da-da-da-da-da. And I finally fell. .I don’t know if it’s all (I/A), all the shits that’s been coming down the last 3 months or if it’s my past catching up with me. {Long pause} But I lived a really, really fucked up life eh [Um hmm], I did (I/A) like I was a mess worse than so now, worse than now [Um hmm] pardon me [Um hmm], more so than now. {Long pause} For 7 years in (I/A) penitentiary watching people dying by the knife blade and [Yeah] hockey sticks and having nightmares and shit at night eh? {Long pause} I don’t need this in my life right now when this is (I/A), things are starting to get back on track, it starts happening to me.  with professional helping relationships having different effects in each. The analysis revealed structural and individual circumstances that may explain differences among the classes. Not everyone had an equal chance of remaining stably housed: specific subgroups of people facing severe and multiple disadvantage face unique and different adversities so that interventions are not equally effective for different subgroups of homeless people. At the start, being male, the number of adverse childhood experiences, and being in the treatment-as-usual group reduced tenancy security. Older participants who received the intervention were more likely to remain in their homes over the study period. However, when the strength of the working alliance between the worker and participant was also considered, the above variables no longer predicted housing stability, demonstrating the importance of relationship quality.There is overlooked heterogeneity in the recovery profiles of highly disadvantaged individuals , in the first year for another group (Class 1), and not at all for a third group (Class 2). Research has shown that an early onset of homelessness is associated with numerous childhood problems , psychiaThe qualitative analyses revealed a number of possible reasons for this class variation. In line with previous work , 19, indCounter-intuitive impacts were found. A stable home can produce time for reflection, bringing to the present guilty feelings about the impact of past behaviours on family and friends. As Sandu  found, people facing severe and multiple disadvantage have an emotional reaction to their circumstances, which coupled with a distrust of others resulting from a history of poor relationships leads them to back away from potential relationships and supports. Depletion and active avoidance of social connection can make it harder to form and sustain the effects of positive professional relationships. Padgett, Henwood, Abrams, and Drake  also fouThis study also explained significant variations among sub-groups of participants and elucidated the characteristics of high-quality relationships between workers and participants, underlining the importance of a sense of personal connection , 14, 15.There are several limitations to the study. The concept of the working alliance, although widely used, fails to fully capture the essence of worker-client relationships. Sub-components of the working alliance were not identified, although this could have resulted in further understanding of how working alliances function in this population. Inclusion of different outcomes, in addition to housing stability, could have yielded a fuller picture of how relationships affect outcomes. Estimation of the mixture model did not use predefined group membership that could identify different trajectories for intervention and treatment-as-usual groups, although in the only study that has done this , the besThe study also had several strengths. It added to a body of evidence showing that professional helping relationships can have positive effects in severely disadvantaged groups , 21. TheThe quality of professional helping relationships made a significant contribution to the housing stability of people experiencing homelessness and mental illness, with different effects detected on unique subgroups within the homeless population. Attention to structural and individual factors may ensure that more people benefit from the relationships developed with the workers charged with their support.


Social media platforms, such as Facebook, Twitter, and Instagram, are now part of almost everyone's social life, especially for the newer generations. Children and teenagers grew up together with these Internet-based services, which have become an integral part of their personal and social life. However, as reported in various studies, psychological and psychiatric problems are sometimes associated with problematic usage of social media. The primary purpose of this review is to provide an overview of the cognitive, psychological, and social outcomes correlated with a problematic use of social media sites during the developmental stages, from age 10 to 19 years. With a specific focus on depression, anxiety, eating, and neurodevelopmental disorders, the review also discusses evidence related to genetic and neurobiological issues, together with the implications in clinical work and future directions under a multidisciplinary perspective. While the scientific community has made significant progress in enhancing our understanding of the impact of social media on teenagers' lives, more research integrating biological and environmental factors is required to fully elucidate the development of these disorders. Social media is a class of mobile and Internet-based applications that allow people to receive information and to build and share user-generated content. Through the creation of a virtual profile, it is possible to interact with real-life friends, meet new people from all over the world, connect with one's favorite celebrities, and to maintain both online and offline relationships. Since 2004, the use of social media has been increasing rapidly, with the possibility to be connected to the Internet anytime and anywhere. According to the nature of the content, the user can choose, from a wide range of applications, the platform that best suits the purpose of the communication. For example, Facebook is more focused on real-life friends and relatives and encourage interactions through services such as sharing pictures, videos, status updates, and joining groups with specific interests. Social platforms like Twitter, which are also known as “microblogs,” are characterized by brief communication. Other applications, like Instagram or Snapchat, provide photo- and video-sharing services, together with the possibility to like, comment, and re-post preferred content. a window into the secret world of adolescent peer culture, even as it offers young people a new screen for the projection of adolescent developmental issues”  model in conducting a systematic literature review. A search of four scientific electronic databases yielded 42 papers for qualitative evaluation. We searched PubMed Central, PubMed, PsycInfo, and Scopus databases for articles on psychiatric disorders in youths related to social media. Since this topic embraces multiple fields, such as computer science and information and communication technologies, we also browsed the Association for Computing Machinery Digital Library and the Institute of Electrical and Electronics Engineers Xplore Digital Library to find relevant research articles in the proceedings of conferences focused on the role of social media in explaining psychological issues in the developmental age. We comparatively analyzed the literature from 2006 up to the end of July 2020, combining different keywords and Boolean operators. A database was generated by combining terms and Boolean operators, such as “social media” AND “child*,” “social media use” AND “child*,” “social media” AND “disorder” AND “youth*”. To include more targeted records, we conducted a further search on the same databases using terms describing the specific issues we meant to address in this review: (“YouTube” OR “WeChat” OR “TikTok” OR “Reddit” OR “Pinterest” OR “Facebook” OR “Instagram” OR “Twitter” OR “Tumblr” OR “MySpace” OR “Whatsapp”) AND  AND (“adolescent*” OR “youth*” OR “teenager*”).From a methodological perspective, studies had to fulfill the following criteria to be included: journals and proceedings of conference papers published up to the end of July 2020, published in English, and meeting the following criteria:https://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html;participants: children and adolescents until the age of 19 with a profile on at least one of the most popular social media platforms ; we opted to consider the age of 19 as the upper limit of adolescence, in accordance with the definition provided by the World Health Organization interventions: assessment of psychiatric disorders in the developmental ages ;comparison: it is not applicable, as we only included studies based on the sample of social media users;outcomes: we considered the levels of psychological well-being or diagnosis of psychiatric disorders as the outcome;study design: we included studies containing quantitative approaches to produce empirical data and qualitative designs.d). Disorders will be discussed in distinguished macro-categories, divided by diagnostic class, according to the DSM-5 and the figure chosen as the desirable self-image”  have been spreading across social media platforms. The dynamics of the Proana Movement, which promotes behaviors relating to anorexia nervosa, have been examined using Twitter, finding that adhering people and/or promoters were almost totally teenage girls . In the Adolescence is the stage of life where people gain more independence and make new experiences in their social environment, where peer influence might encourage and provide opportunities to come into contact with alcohol, potentially leading to the development of an addictive behavior toward the substance. As the social environment is now composed of two realities, online and offline, it is crucial to understand the contribution of social media in fostering, maintaining, or conveying contents related to substances. Studies on drinking behavior among teenagers and social media use highlight that online platforms like Facebook might represent a helpful tool to detect problematic alcohol use , 92, 93,Channel News Asia for a recent episode). Although researchers attempted to study the extent of social media on suicidal behaviors in-depth, complexities derive from legal and privacy issues, as well as from the indirect association between the usage on web-based platforms and the suicide itself  and suicidal intention . Social e itself .the article by Petrov C. on statistics about cyberbullying, February 28, 2019). As the contents are shared and spread quickly online, the victim can experience, besides a lack of control, a series of highly negative psychological consequences, such as social anxiety . Likewise, in 2015, Twitter activated a safety center for parents and teens with guidelines for a more secure navigation and utilization of the site. Furthermore, they founded the Twitter Trust and Safety Council that works in partnership with several institutions and organizations in order to direct users to the appropriate service in case of abuse (see Twitter Safety Partner). With regard to Instagram, which has been owned by Facebook since 2012, the platform presents the community guidelines and another section where parents can find more information about the accessibility and visibility of their children by other users. Moreover, an online form is available for reporting self-injury material, hate comments, abusive or inappropriate content, and profiles belonging to teens younger than 13 years old, which is the requirement to own a profile (see Instagram Privacy and Safety Center page). The same subscription criteria are applied to YouTube, although videos posted by other users are accessible even without owning a profile. Because of this, it is possible for parents to set restrictions in order to avoid potentially dangerous or improper material. In addition, together with the site policies, informative material about harmful behaviors such as self-injury, suicide, harassment, and cyberbullying is provided (see YouTube Community Guidelines). So far, statistics about the efficacy of these safety measures have not being available. Generally, targeted services for prevention have been made known on the most popular online platforms by providing users with links to websites, hotlines, and information about how to detect warning signs of suicide. Web communities focused on suicide prevention have been founded, giving their members the opportunity to share their own direct or indirect experience in an anonymous way and to support each other, without the constraints of physical boundaries  study conducted by Meshi and colleagues reports that social media engagement is linked to activity in the ventral striatum (vSTR) and adjoining structures of the nucleus accumbens . More prnomophobia,” “selfie,” “phubbing,” “FoMO,” and “vaguebooking” have appeared for some years, defining specific behaviors or state of minds, that need further analysis, as they represent new, unexplored facets of human behavior. Research in psychological fields would also benefit from the exploration of specific types of interaction, such as the creation of multiple accounts, the fruition of live streaming video services, and behaviors like un-tagging people from posts or pictures or unfollowing/unfriending people in order to better understand the effects of mechanisms related to virtual social inclusion or exclusion. Although social media allows for greater ease of recruitment and testing of a greater number of participants in more efficient ways—sometimes comparable to laboratory testing sessions , middle adolescence (15–17), and young adulthood (18–21), as the early adolescence population should not be able to access and be engaged in virtual interactions on such platforms. This issue rebounds in a lack of studies considering this distinction, representing a further challenge to future research. Lots of efforts have been invested in creating new tools for assessing people's attitudes toward social media usage, such as the creation and validation of new scales , 125–129sessions —a lack oIC, GE, and BL conceived the paper. IC performed the search, interpreted the literature, and wrote the paper. GE, MN, and BL reviewed and edited the paper. GE submitted the paper. All the authors reviewed the final version of the paper before submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.