Designing Effective Mobile Health Apps Does Combining Behavior Change Techniques Really Create Synergies

Journal of Management Information Systems
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/mmis20
Designing Effective Mobile Health Apps: Does

Combining Behavior Change Techniques Really
Create Synergies?
Kai Spohrer, Monica Fallon, Hartmut Hoehle & Armin Heinzl
To cite this article: Kai Spohrer, Monica Fallon, Hartmut Hoehle & Armin Heinzl (2021)
Designing Effective Mobile Health Apps: Does Combining Behavior Change Techniques
Really Create Synergies?, Journal of Management Information Systems, 38:2, 517-545, DOI:
10.1080/07421222.2021.1912936
To link to this article: https://doi.org/10.1080/07421222.2021.1912936
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JOURNAL OF MANAGEMENT INFORMATION SYSTEMS
2021, VOL. 38, NO. 2, 517–545
https://doi.org/10.1080/07421222.2021.1912936
Designing Effective Mobile Health Apps: Does Combining

Behavior Change Techniques Really Create Synergies?
Kai Spohrera, Monica Fallona, Hartmut Hoehleb, and Armin Heinzla
a
General Management and Information Systems, University of Mannheim, Mannheim, Germany; bEnterprise
Systems, University of Mannheim, Mannheim, Germany
ABSTRACT KEYWORDS
Although several theories could be applied to stimulate mobile health Mobile health; design
(mHealth) use and change people’s health behaviors, theory-driven science; social comparison;
mHealth designs are scarce. Instead, developers and researchers often protection motivation; fear
appeals; stress management;
implement behavior change techniques and mix multiple techniques
behavior change theory
without explicitly considering their underlying theoretical mechan
isms. We call this practice into question and propose that combining
behavior change techniques does not necessarily result in synergistic
effects. Drawing on theories of protection motivation and social
upward comparison, we engage in explanatory design theorizing to
understand interactions of behavior change techniques and their
implications for mHealth design. We design, theorize about, and eval
uate four mHealth prototypes for stress alleviation. In a five-week field
experiment with n = 138 participants and a subsequent qualitative
substantiation, we show that there is a negative interaction effect of
protection motivation and social upward comparison, rendering their
combined application less effective. Our findings elicit mutual bound
ary conditions for theories of protection motivation and social upward
comparison. If mechanisms of one theory are present, they restrict the
effectiveness of mechanisms of the other theory. Thus, mHealth devel
opers need to use caution when combining different behavior change
techniques within one mHealth artifact.
Introduction
Mobile health (mHealth) (i.e., the practice of medicine and public health supported by
mobile device functionalities and applications [66]) is playing an increasingly important
role in enabling individuals to manage their health [2]. Given the benefits of mHealth, many
organizations, such as Barclays, IBM, Time Warner, and Target, have begun to incorporate
mHealth into corporate wellness programs to improve the health, well-being, and perfor
mance of their employees [18]. However, the extent to which individuals actively use
mHealth is often limited to few initial interactions and, thus, reduces the effectiveness in
improving users’ health behaviors and health outcomes [33]. Although a substantial
amount of money is invested to increase mHealth app use, only 4 percent of mHealth
developers manage to acquire more than 1 million downloads annually and only 30-40 per
cent of first-time users convert into active users [49]. The development of mHealth
CONTACT Kai Spohrer spohrer@uni-mannheim.de University of Mannheim Chair of General Management and
Information Systems, L15, 1-6, 68161 Mannheim, Germany.
Supplemental data for this article can be accessed on the publisher’s website
© 2021 Taylor & Francis Group, LLC
518 SPOHRER ET AL.
applications that stimulate active use therefore constitutes an enduring challenge of high
practical relevance [39].
Although there are a number of strong, empirically backed theories on health behavior
change that could guide mHealth developers in designing more frequently used and
effective mHealth, mHealth practice does not usually draw on theory [31]. Instead, it has
focused on combining behavior change techniques, such as goal setting or social comparison
[16, 36]. Behavior change techniques are defined as “an observable, replicable, and irredu
cible component of an intervention designed to alter or redirect causal processes that
regulate behavior” [42, p. 82]. Contemporary mHealth applications often draw on combi
nations of several such behavior change techniques [16, 36]. On average, recent reviews
found five distinct behavior change techniques per mHealth application in academic studies
[43]. This is likely due to the fact that current mHealth practice and much extant research
assume that combining multiple behavior change techniques results in synergistic effects,
which implies that behavior change techniques are commensurable and that combining
them results in more advantageous outcomes [17].
However, many health behavior change theories and behavior change techniques have
fundamentally different and potentially incommensurable underlying mechanisms, mak
ing the assumption of synergistic effects highly questionable. For example, prominent
behavior change techniques, such as fear arousal and social influence stem from separate
lines of investigation and build on different theoretical mechanisms [13, 30, 41, 42]. We
propose that such behavior change techniques draw on mechanisms that may actually
counteract or be fundamentally incommensurable. In line with this argument, recent
mHealth meta-analyses found no significant positive effects of greater numbers of com
bined behavior change techniques on behavioral outcomes [43]. Therefore, we suggest
that combining behavior change techniques without considering the theoretical mechan
isms underlying them may actually have a negative effect on outcomes rather than
synergistically improve them.
A dominant focus on behavior change techniques, rather than theories, could also be
problematic from a research perspective. Behavior change techniques have been proposed
as a unit of analysis that can be decoupled from their theoretical origins because behavior
change techniques are potentially related to multiple theories, well-defined, and repro
ducible, which facilitates their implementation and comparability across different settings
[41, 42]. We follow recent work that suggests it may be important to account for the causal
mechanisms that underlie each behavior change technique to truly understand their
effects [13, 30]. More specifically, the basic premise of our research is that a theory-free
focus on behavior change techniques may lead to combinations of counteracting mechan
isms in mHealth designs that obfuscate the techniques’ effects and prevent reliable
empirical evaluations. In that case, an overly narrow focus on behavior change techniques
and their combination would limit our ability to gain theoretical insights, understand
boundary conditions, and elicit incommensurability of causal mechanisms.
We call the focus on behavior change techniques in mHealth into question and aim to
show that there are combinations of wide-spread and accepted behavior change techniques
that mutually dampen their effects because they build on counteracting and incompatible
theoretical mechanisms. To do so, we turn to two popular behavior change theories that are
frequently embodied in widely used behavior change techniques [13, 30], namely social
upward comparison theory [20] and protection motivation theory [52]. Although these
JOURNAL OF MANAGEMENT INFORMATION SYSTEMS 519
theories both explain and predict health behavior change, they originate from distinct lines
of research and entail very different theoretical mechanisms. Specifically, protection moti
vation theory works through a fear arousal mechanism whereas social upward comparison
theory works through a social influence mechanism. Prior work provided much empirical
support for each of the two theories and their theoretical mechanisms in isolation, but their
interactions remain largely unexplored.
Against this backdrop, this study has the following goals:
(1) Combine and contrast social upward comparison and protection motivation as two
popular theoretical mechanisms of behavior change in mHealth;
(2) Theoretically develop how the mechanisms should negatively interact;
(3) Instantiate the theories in prototypes of an mHealth artifact;
(4) Empirically evaluate the predicted effects using the mHealth artifact.
To achieve these goals, we follow one of the less prominent design science approaches in
information systems (IS) literature: explanatory design theorizing [47, 67]. Explanatory
design theorizing is particularly suitable for our study because it explicitly considers the
interdependence of simultaneously implemented design features and informs designers
which features should be included in an artifact and why [45].
This study contributes to the information systems (IS) literature in four key ways. First, this
research bridges the theoretical boundaries between social comparison theory and protection
motivation theory. We theorize why and empirically show that their combination negatively
impacts mHealth use. Second, we illustrate that combining behavior change techniques does
not necessarily result in synergistic effects. This finding contributes to research on behavior
change techniques and calls widely held assumptions of synergies into question [13, 30].
Third, we showcase that building dedicated new technology is a promising way to create
insights into theoretical mechanisms that drive user behavior. Specifically, we use explanatory
design theorizing to develop prototypes based on two kernel theories and test hypotheses in
the domain of mHealth use. Finally, from a practical perspective, our study has important
implications for integrating behavior change techniques in mHealth design. The findings help
improve mHealth designs by considering underlying theoretical mechanisms. Our instantia
tions of the two theories can be used by future mHealth practice.
In the following sections, we review research on mHealth, explain how combining
behavior change techniques can have undesirable effects, and identify protection motivation
and social upward comparison as appropriate theories to study this issue. Then, we provide
comprehensive design recommendations for instantiating protection motivation and social
upward comparison in mHealth. Four prototypes of an mHealth app are developed and
evaluated in a field experiment with n = 138 participants and a subsequent qualitative
substantiation. Comparing variations of the mHealth app, we assess the effectiveness of
design instantiations in stimulating use and evaluate interaction effects.
Questionable Assumptions in mHealth

Prior reviews of mHealth literature show that mHealth designs based on behavior change
theories are not common (Table 1). Instead, mHealth research has often focused on designs
based on behavior change techniques.
520 SPOHRER ET AL.
Table 1. Behavior change techniques and behavior change theory in mHealth.

Study Finding Conclusion & Gap
Behavior Change Techniques in mHealth
Christmann et al. (2017) [14] The average stress app in major app stores The majority of mHealth apps in research
has 4.3 behavior change techniques and practice include several behavior
Conroy et al. (2014) [16] The average physical activity app has 4.2 change techniques. But it is unclear if
behavior change techniques incorporating multiple behavior change
Lyons et al. (2014) [36] 5 behavior change techniques were most techniques results in synergistic effects.
widely represented among devices
Milne-Ives et al. (2020) [43] mHealth apps in academic studies contain 5
behavior change techniques on average
Zhao et al. (2016) [68] 91 percent (21/23) of reviewed mHealth
studies explicitly reported the behavior
change techniques incorporated
Behavior Change Theories in mHealth
Al-Durra et al. (2015) [4] 20 percent (17/85) of reviewed mHealth Even in mHealth research, the majority of
studies applied at least one model, mHealth app designs do not explicitly
framework, and/or construct from build on behavior change theory.
a behavior change theory
Milne-Ives et al. (2020) [43] 50 percent of mHealth apps in academic
studies do not draw on any behavioral
theory
Sawesi et al. (2016) [54] 32 percent (14/44) of reviewed mHealth
studies reported behavior change theories
Zhao et al. (2016) [68] 26 percent (6/23) of the reviewed mHealth
studies reported a behavior change theory
Both mHealth practice [16, 36] and research [17, 43] often combine multiple behavior
change techniques into a single artifact. The line of thought underlying these combinations
originates from the idea that behavior change techniques can be more easily delineated,
implemented, and reproduced than instantiations of complete theories [1, 41, 42]. However,
the focus on isolated behavior change techniques has sometimes led to oversimplifying
conclusions regarding their combined effects. Specifically, mHealth research usually
assumes that positive effects of behavior change techniques are mutually reinforcing
when the techniques are combined [17].
Figure 1 visualizes two frequently found questionable conclusions from valid studies on
isolated behavior change techniques: Imagine two rigorous studies on the isolated effects of
behavior change techniques X and Y, respectively. Both X (Figure 1a) and Y (Figure 1b) are
validly shown to have significant positive effects on use and health outcomes. Questionable
conclusions can occur when it is assumed that the isolated techniques’ positive effects simply add
up (Figure 1c) or that the techniques even complement each other and create synergies (Figure
1d). We challenge these assumptions and argue that behavior change techniques can actually be
incommensurable and counteracting due to their underlying theoretical mechanisms.
In line with our argument, meta-analyses on whether a combination of behavior change
techniques leads to synergistic effects provide mixed results [43, 68]. They show that the
combination of behavior change techniques in mHealth is often piecemeal with the
combined techniques stemming from different theoretical origins [30, 43]. Effects on
behaviors, however, do not result from techniques themselves, but from the causal mechan
isms underlying them [41] and their cognitive evaluation [29]. If two behavior change
techniques are combined that trigger counteracting mechanisms, the effect should be lower
than the sum of positive effects or even negative. If such negative interactions of individually
beneficial techniques are common, solely integrating behavior change techniques without
considering their theoretical basis would clearly offer little value. It is so far unclear,
however, whether and to what extent such interactions of counteracting techniques indeed
influence mHealth use and outcomes. Moreover, we are not aware of any studies elaborat
ing such counteracting effects and their consequences for common behavior change
techniques in mHealth.
Figure 1. Questionable assumptions about synergistic effects of behavior change techniques. BCT,
behavior change technique.
Theoretical Background
To show the harmful potential of combining behavior change techniques without consider
ing their underlying theoretical mechanisms, we turn to social upward comparison theory
and protection motivation theory and examine their combination. These theories are two of
the most prominent behavior change theories with distinct theoretical mechanisms and are
frequently embodied in behavior change techniques [13, 30]. Whereas social upward
comparison is abundantly used in many mobile applications in features such as leader
boards or contests, protection motivation with its fear arousal mechanism is particularly
present in the healthcare context because “apparently the allure of obtaining the positive
benefits of health enhancement does not have the persuasive appeal of avoiding the negative
consequences” [51, p. 20]. In the following section, we elaborate the mechanisms underlying
these theories and conceptualize how they can counteract.
Social Upward Comparison Theory

Social upward comparison theory [20] works through a social influence mechanism, in which
comparing upwards to better performing others influences individuals’ self-evaluations of
their abilities. Viewing information on others who perform better than oneself stimulates
individuals to self-evaluate how their performance on the dimension of interest compares to
522 SPOHRER ET AL.
others’ [20]. If social upward comparison creates a perceived negative discrepancy between
individuals' own and others' performance, it stimulates them to take action to reduce the
discrepancy [20]. Prior work shows that self-evaluating one’s abilities in comparison to better
performing others can be encouraging, inspiring and self-motivating [60]. Stressed and
threatened individuals may compare upward to seek information on how better-off others
are coping with a problem, which allows them to gain inspiration and hope [60].
The boundaries of the positive effects of social upward comparison are, however, not so
clear-cut. Social upward comparison is sometimes interpreted as a social threat, in which
better performing others can threaten one’s self-esteem and perception of abilities [22].
Accordingly, researchers have studied how experiencing different types of threats influences
social comparison. Some scholars suggested that people experiencing a health threat, such as
cancer, rheumatoid arthritis, and chronic pain may compare more downwards than upwards
[61]. Meta-analyses suggest, however, that the presence of a threat can possibly reduce
upward comparison but comparing upward remains a predominant human preference [58].
Behavior change techniques instantiating elements of social upward comparison are
widely used in mHealth [36] and to understand app usage [69], for example in features
such as leaderboards and performance visibility. However, the extent to which social
comparison features interact with other commonly integrated features in mHealth remains
unclear [7]. On a more fundamental level, it remains unclear how the social influence
mechanisms underlying social upward comparison interact with the theoretical mechan
isms underlying other behavior change techniques.
Protection Motivation Theory

Protection motivation theory [52] works through a fear arousal mechanism. It explains how
a specific type of persuasive message, called a fear appeal, creates cognitive perceptions of
a threat and one’s ability to cope with it [37]. Fear appeal messages initiate a cognitive
appraisal of a threat and of one’s possibilities to respond to the threat [10, 37, 44]. According
to protection motivation theory, individuals will evaluate their coping abilities and even
tually act to alleviate a threat if the threat is appraised as relevant and potentially harmful
[44]. Threat appraisal consists of assessments of threat severity (i.e., the extent to which the
individual perceives the consequences of the threat as important) and threat susceptibility
(i.e., the individual’s perceived chances to be harmed by the threat). Next, users appraise the
possible response to the threat, referred to as the coping appraisal. The coping appraisal
consists of assessing the response efficacy (i.e., the degree to which one believes the
recommended response will effectively avert the threat), one’s self-efficacy (i.e., one’s ability
to alleviate the threat), and potential response costs (i.e., the acceptability of costs for
performing the response). These cognitive appraisals mediate the persuasive effects of
a fear appeal through protection motivation, which arouses, sustains, and directs activity
to protect the self from danger [37].
Generally, protection motivation theory appears to do a good job at explaining why and
how fear appeals can change IS-related behavior. IS researchers have relied on protection
motivation theory to study and influence user behaviors in IS security, including backup
software use [10], anti-malware use [28], and compliance with guidelines [55]. Likewise,
protection motivation explains mHealth acceptance and adoption behavior [24] and has
been widely used in public health campaigns to change health behaviors [44]. Typical
behavior change techniques based on protection motivation theory include fear appeal
messages that contain threats of future health consequences or punishment, verbal persua
sion of one’s capabilities, and skill information [17, 42].
Despite the positive effects of protection motivation theory in persuading users to enact
a behavior, prior work has not clearly outlined the boundary conditions under which
protection motivation is effective. In particular, fear appeals are often presented to indivi
duals in minimally social contexts [65]. Thus, it is unclear how fear arousal mechanisms
underlying protection motivation theory interact with social influence mechanisms.
Studying such interactions is important because the impact of fear appeals is not uniform
across all users and may in part be determined by perceptions of social influence. In prior IS
research on protection motivation, social influence showed the strongest predictive ability
for adopting IS security behaviors compared to coping appraisals and threat appraisals [28].
Thus, IS research has called for research that helps to better understand social factors in
protection motivation models [10]. Although not fully evaluated, these statements suggest
that social influence mechanisms may counteract fear arousal mechanisms. Consequently,
we follow a design science approach that allows us to evaluate interactions between social
upward comparison and protection motivation in mHealth.
Research Method: Explanatory Design Theorizing

Explanatory design theorizing is a genre of design science research that aims to inform
designers about which features should be included in an artifact and why [47]. The outcome
of explanatory design theorizing consists of rigorously validated hypotheses whose inde
pendent variables are instantiated in design features based on kernel theories [45]. The
research phases, challenges, and quality criteria of explanatory design theorizing differ
slightly from other genres of design science research [45]. Specifically, explanatory design
theorizing has six phases: 1) identifying a scientifically and practically relevant design
problem; 2) choosing appropriate explanatory kernel theories for the problem; 3) instantiat
ing the independent variables of the theories in design features; 4) developing hypotheses on
the effects of the instantiations based on the kernel theories; 5) rigorously evaluating the
hypotheses by comparing effects of design features; and 6) interpreting the evaluation
results regarding the desirability of specific design features, thereby creating a mid-range
theory of the design of artifacts [34,45]. Although explanatory design theorizing has not
received as much attention as other genres of design science research [47], it is a particularly
suitable method for our research because it explicitly acknowledges the need to account for
interdependence of simultaneously implemented design features [45]. Although the devel
oped artifacts should be useful, explanatory design theorizing differs from other design
science genres in that the novelty of the final artifact is not at the center of explanatory
design theorizing. Instead, the key quality criteria are the faithfulness of the representation
of theoretical variables in design features, the deductive validity of hypotheses, and the
rigorous evaluation of hypotheses [47]. Table 2 outlines the steps of explanatory design
theorizing and the sections of this paper that describe how each of the steps was conducted
in this study.
The Theory-Guided Instantiation section describes how we instantiated protection moti
vation and social upward comparison in mHealth. We developed mHealth design features
that enabled us to examine how the two theories unfold effects in isolation and in
524 SPOHRER ET AL.
Table 2. Design science approach: Explanatory design theorizing.

Based on Niehaves & Ortbach (2016) [45] Current Paper
Step Description Section Description
Selection of Kernel Theories Justificatory knowledge from Theoretical Background We describe kernel theories
kernel theories and how it of protection motivation
can be theoretically and social upward
related to the explanatory comparison and show that
aspect of design there could be negative
interactions between their
mechanisms.
Instantiation Instantiation of the kernel Theory-Guided We instantiate theoretical
theory into an artifact with Instantiation mechanisms of protection
manifest design features motivation and social
upward comparison into
an mHealth artifact,
describe four prototypes,
and provide general
design recommendations.
Hypotheses Development Explains why specific design Hypotheses Development We theorize how and why the
features cause effects social comparison and
based on kernel theory protection motivation
prototypes will affect use
in isolation and how their
combined instantiation
will interact to affect use.
Comparative Design Develop different artifact Empirical Evaluation We empirically evaluate four
Evaluation versions through prototypes based on social
prototyping and upward comparison,
empirically evaluate protection motivation, and
effects their combination in a 5-
week field experiment and
a qualitative
substantiation.
Interpretation of Evaluation Interpreting differential Evaluation Results We interpret the empirical
Results effects of prototypes on results with regard to the
outcomes regarding the desirable and undesirable
desirability of design effects of social upward
features comparison, protection
motivation, and their
combination on mHealth
use for practice and
research.
combination. In the Hypotheses Development section, we then hypothesize beneficial main

effects and counteracting interaction effects of the instantiations based on the theoretical
mechanisms that underlie them. In the Empirical Evaluation section, we describe how we
validated the instantiations, developed four mHealth prototypes based on the instantiations,
and empirically evaluated their effects on mHealth use through a field experiment. Design
science experiments are not only effective at collecting objective usage data, but are
particularly valuable when gathering user reactions and perceptions that help assess the
adequacy of a designed artifact [40, 63]. In the Evaluation Results section, we report and
interpret the results of the evaluation.
Theory-Guided Instantiation
To instantiate the theories of social upward comparison and protection motivation into
mHealth, we utilize elementary features of smartphones, namely, the continuous availability
of user data and push notifications. Contemporary smartphones and mobile networks allow
for close tracking of user activities in self-developed apps, collecting usage data, as well as
for analyzing, visualizing, and reacting to usage patterns. Moreover, users can typically be
reached at nearly all times through push notifications. These notifications can be pushed to
users so that they are displayed in the active view of the users’ smartphone, thus making it
nearly impossible to avoid the information. We rely on these elementary smartphone
features to create transferrable, manifest mHealth design features that completely represent
the theories’ independent variables and trigger the social upward comparison and protec
tion motivation mechanisms that stimulate increased mHealth use.
To become effective, the social upward comparison mechanism requires that individuals
perceive a negative discrepancy between their own and others’ performance on a compar
ison dimension and that no negative side-effects of social upward comparison overlay the
respective motivational effects. Thus, instantiations of social upward comparison theory in
mHealth need to clearly point users to a comparison dimension, ensure that the users
become aware of a negative performance discrepancy, and prevent three common side-
effects: envy and inter-personal quarrels [57], damage to self-esteem [22], and privacy
concerns [6]. Social upward comparison induces envy when a referent is perceived as
extremely superior, but still very similar to oneself [32]. Accordingly, close friends and
acquaintances at the top are the most common envy targets [26]. Social upward comparison
can damage one’s self-esteem if one feels that others witness the fact that one is doing much
worse than they are [22]. Finally, there have been escalating concerns about information
privacy in healthcare settings [6]. While mHealth rarely accounts for privacy concerns [59],
individuals are hesitant to disclose sensitive health information, even if they compare
themselves to others based on this information [6]. Accordingly, we developed messages
and visual displays that point mHealth users to a comparison dimension, show the user’s
negative performance discrepancy, and mitigate the common side-effects.
Tables 3a and 3b show the developed social upward comparison features in detail. We
developed push messages that suggest mHealth use as a comparison dimension, highlight
a negative discrepancy in mHealth use, and encourage users to make more detailed upward
comparisons using a performance visibility page. The developed performance visibility page
displays a graph, in which the average frequency of mHealth use of all other users is shown
in comparison to the focal user. The displayed data are automatically manipulated so that
the displayed average of mHealth use by all users is higher than the individual user’s. The
data manipulation ensures that all users can only compare upwards. Displaying the average
frequency of mHealth use by all users forces each user to compare to the anonymous
collective of all users, rather than comparing to individual users who perform better.
Displaying only anonymous usage data prevents the common side-effects of social upward
comparison: Without a personally identifiable target, users cannot develop envy to better
performing individuals; without explicit individual usage patterns, users do not have to fear
unfavorable evaluations by other users and potential losses in self-esteem as others cannot
look down on them; without details about individuals, users do not have to fear that their
health data are disclosed to other users.
We instantiated protection motivation theory into mHealth through fear appeal push
messages. Following the specification of protection motivation theory that has frequently
been applied in IS research [28,55], fear appeals contain a threat appraisal, which empha
sizes on threat severity and susceptibility, and a coping appraisal, which emphasizes on self-
526 SPOHRER ET AL.
Table 3. Social upward comparison.

3a. Theoretical elements, principles, and features.
Theoretical Element Principles and Features Example
Determining a Comparison Push notifications hint users to mHealth use as
Dimension a comparison dimension and guide them to
performance visibility page. The performance
visibility graph contrasts the user’s mHealth use
(number of trainings completed) with other
users’ app use.
Recognizing a Negative Push notifications suggest a negative discrepancy.
Discrepancy Performance visibility page displays the user’s
performance as lower than the average
performance of other users.
Preventing Common Side Average scores for other users prevent envy,
Effects threat to self-esteem, and data privacy concerns
compared to non-anonymous forms of social
comparison.
3b. Push messages and their components.
# Comparison Dimension Performance Discrepancy Further Upward Comparison
SUC1 What’s up? Your peers seem to exercise more than you with WORKLAX! The profile page shows
details.
SUC2 Huh? Looks like you are using WORKLAX less than others do! The profile page shows
details.
SUC3 What’s up? Your WORKLAX activity appears to be lower than for other users. The profile page shows
details.
Note: For communication with participants, we called the developed mHealth application WORKLAX.
Table 4. Protection motivation: Theoretical dimensions, principles, and features.

Theoretical Dimension Principles and Features Example
Threat Appraisal Severity Push notification emphasizes the severity of the health
threat
Susceptibility Push notification emphasizes the susceptibility of the
health threat
Coping Appraisal Response-Efficacy Push notification emphasizes how to avert the health
threat
Self-Efficacy Push notification emphasizes one’s ability to avert the
health threat
Response Costs Push notification deemphasizes the costs (e.g. effort,
time) of enacting the health behavior
Note: Online Appendix B lists the fear appeal push notifications used in this study.
efficacy, response efficacy, and response cost. To instantiate these elements, each fear appeal
push message that we developed suggests that a particular health threat (e.g., stress) is
potentially harmful (e.g., impairing performance in sports and school) for groups of
individuals that include the user (e.g., college students). Each message further suggests
that using the specific mHealth app can alleviate this harm effectively (e.g., supporting
physiological stress recovery) and efficiently (e.g., through short and easy exercises). The
fear appeals thereby conform to current IS guidelines [55] by explaining how the threat puts
users at risk, showing concrete negative consequences and proximity of the threat, and
specifying a concrete protection response. The fear appeals are outlined in Online Appendix
B and are displayed in the active view of users’ smartphone as shown in Table 4. The
instantiations were qualitatively validated as described in the Prototyping and Artifact
Development section.
Hypotheses Development
The theory-guided instantiations in Tables 3a and 3b prompt individuals to compare
upward to the collective of other users while the collective exhibits higher performance in
mHealth use. Users who realize that they perform worse than other users regarding the
mHealth app as a comparison dimension will engage in an evaluation of the discrepancy
and of their abilities to reduce it. Given that the displayed score of mHealth use represents
the average mHealth use of all other users, the user can assume that many others use the
mHealth app more often than the average, whereas, again, many others use it less often than
the average. Thus, users can assume that they would drastically reduce the number of
individuals who outperform them if they reach the average score level. The prospect of not
being outperformed has strong motivational effects and triggers the user to engage in
mHealth use. Research on social comparison features in mHealth strongly supports this
reasoning. It shows that social comparison features stimulate users to engage more with
mHealth applications and make them strive to become top performers [62]. Thus, we
hypothesize:
Hypothesis 1 (H1): The social upward comparison instantiation has a positive effect on
mHealth use.
The instantiations of protection motivation theory in Table 4 and Online Appendix B are
consistent with prior work on fear appeals [52, 53]. They should thus trigger fear arousal
and a protection response. Because the developed fear appeal messages include information
about the severity of the threat as well as the user’s susceptibility to the threat (Table 4;
Online Appendix B), users who receive them will evaluate the threat to be relevant and
potentially harmful. Therefore, users will realize the need to evaluate their coping abilities
and act to alleviate the threat if viable [44]. The developed messages state that users can
avert the health threat through mHealth use and suggest that mHealth use does not create
high costs or effort (Table 4; Online Appendix B). Appraising their coping possibilities,
users will thus perceive mHealth use as an effective and efficient protection from the threat.
Consequently, they will more likely exhibit increased mHealth use as a viable protection
response to the relevant and harmful health threat. This reasoning is supported by prior
work on mHealth, which showed that fear appeal messages can play an important role in
mHealth acceptance and adoption behavior [24]. We hypothesize:
Hypothesis 2 (H2): The protection motivation instantiation has a positive effect on

mHealth use.
528 SPOHRER ET AL.
H1 and H2 posit that the instantiations of protection motivation and social upward
comparison theory in isolation have positive effects on mHealth use. At a first glance, it may
seem that combining them should yield synergistic effects and further increase mHealth use.
However, based on the mechanisms underlying them, we suggest that their combination
instead results in a negative interaction effect for two reasons.
First, the mechanisms create contradictory perceptions of threat and abilities. On the one
hand, fear appeal messages emphasize on the harm that may result from not making full use
of one’s abilities to avert a health threat. On the other hand, social upward comparison
information can threaten one’s perceived abilities by showing that one’s performance is
inferior to that of others. Through fear appeal messages, individuals develop a desire to
alleviate the threat to their personal health, thereby focusing on themselves and their own
abilities to cope with the threat; through social upward comparison, individuals may
question their abilities and shift the focus from their own ability to avert the health threat
towards their relative, and possibly inferior, abilities compared to others. Thus,
a combination of social upward comparison and protection motivation sends contradictory
and daunting signals.
Second, the static nature of fear appeals does not correspond with the dynamic nature of
social comparison. As such, fear appeals entail static threats. However, the perceived
susceptibility to a health threat is lower if one is acting to alleviate the threat [11].
Accordingly, fear appeal messages show weaker effects over time because users feel less
threatened as they enact a protection response. Social upward comparison, by contrast, is
dynamic and maintains its effects over time. As long as one is not the sole top performer,
one can still draw motivation from comparing one’s standing to better performing others,
even after the adoption of a new health behavior. In mHealth, dynamic social comparison
information may actually show users that they have adopted a recommended response
while simultaneously received fear appeal messages emphasize that the original threat still
exists. Thus, we propose that their combination sends mixed signals and results in less of the
desired behavior. We hypothesize:
Hypothesis 3 (H3): Combined instantiations of protection motivation and social upward

comparison have a negative interaction effect on mHealth use.
Empirical Evaluation
We implemented the instantiations of protection motivation and social upward comparison
theory in an mHealth artifact in one specific mHealth domain, namely stress alleviation. We
developed four prototypes of the artifact which we refined and validated iteratively. The
main evaluation of the hypothesized effects then consisted of a five-week randomized field
experiment.
mHealth Domain: Alleviating Stress

We chose alleviating stress as an mHealth domain to evaluate the instantiations of protec
tion motivation and social upward comparison theory. The artifact focuses on stress
reduction with progressive muscle relaxation exercises. We set this focus on alleviating
stress for three reasons. First, harmful stress is extremely common in knowledge workers,
professionals, and students [8]. As such, most U.S. adults experience stress on a moderate to
severe level daily [5]. Second, the alleviation of harmful stress can be effectively supported
by adequately designed personal health technology [14, 27], but few studies address the
design and evaluation of mHealth stress applications rigorously [21]. Third, there are few
stress management apps in Apple’s and Google’s app stores compared to other mHealth
domains [14, 27]. Recent studies and meta-analyses of evidence-based methods for stress
alleviation suggest that especially progressive muscle relaxation constitutes a promising
method that lacks implementation in mHealth [14, 27]. Our review of existing stress
management apps in both app stores conducted in 2020 (detailed review in Online
Appendix F) confirmed that implementations with progressive muscle relaxation are scarce.
In contrast to other stress alleviation methods such as meditation, keeping special diet, and
physical engagement in yoga or tai-chi, progressive muscle relaxation builds on relatively
short and inconspicuous exercises that can be conducted during work or school without
drawing much attention [19, 25].
Prototyping and Artifact Development

To examine the interaction effects of our theory-guided instantiations, we developed four
prototypes of an mHealth artifact for stress alleviation with progressive muscle relaxa
tion: a social upward comparison prototype (featuring the instantiations in Tables 3a
and 3b), a protection motivation prototype (featuring the instantiations in Table 4 and
Online Appendix B), a combined prototype with social upward comparison and protec
tion motivation instantiations (featuring the instantiations in Tables 3a, 3b, and 4 and
Online Appendix B), and a control prototype with none of the aforementioned
instantiations.
The four prototypes share the baseline artifact functionality that covers the three most
frequently found baseline elements of mHealth apps for stress management (i.e., provide
instructions, information about consequences, and information about behavior-health link)
[14, 27]. Specifically, the baseline artifact contains a training view and an information view
for conducting relaxation exercises (see Table 5). The training view guides the user through
3-minute training sessions consisting of three 1-minute muscle relaxation exercises each.
The exercises are based on popular guidelines for progressive, minute-based muscle relaxa
tion [19, 25]. The information view provides a way for users to learn more about the
exercises and how they affect the distinct muscle groups. Exercises are displayed along the
categories “Eye,” “Neck,” “Shoulders,” and “Mixed.” For each exercise, there are descrip
tions and details on why the exercise helps to reduce stress.
We ensured the usability of the artifact during the development process and during the
empirical evaluation by multiple means. Online Appendix C provides details on the
procedures. We also tested how potential users reacted to the design features we imple
mented in the prototypes. Specifically, we acquired 30 student participants (aged 20-29, 19
female, 11 male) to collect their reactions to the artifact. Participants were observed when
confronted with one of the prototypes and subsequently interviewed. They provided feed
back on the usability of the application, on potentially desirable additional features, and on
their feelings about the manifest design features. We ensured that the relaxation exercises
were perceived as easy to follow and understand. We moreover asked about the design
530 SPOHRER ET AL.
Table 5. Baseline features (all participants had these features).

View
Training View Information View

Function Overview of three 1-minute exercises Detailed instructions about how to perform each individual exercise.
included in the 3-minute training. Aimed to increase user perceptions of the effectiveness of the
training.
Table 6. Experimental design with prototype features.

No PM PM
No SUC Control Prototype (n = 41) PM Prototype (n = 35)
● training view ● training view
● information view ● information view
● fear appeal push notifications
SUC SUC Prototype (n = 32) Combined (SUC ± PM) Prototype (n = 30)
● training view ● training view
● information view ● information view
● SUC push notifications ● SUC push notifications
● performance visibility page ● performance visibility page
● fear appeal push notifications
Notes: PM, protection motivation; SUC, social upward comparison.
features related to protection motivation and social upward comparison to verify that they
transmitted the desired messages. In the interviews, the participants confirmed the isolated
motivational effects related to protection motivation and social upward comparison
features.
Evaluation Procedure
The main evaluation of the hypothesized effects consisted of a five-week randomized field
experiment with n = 138 students in a 2 x 2 between-person design. Table 6 outlines the
experiment design. At the beginning of the experiment, participants completed a pre-
questionnaire about demographics and control variables. Then, participants were randomized
into four groups and asked to install a specific one of the four prototypes (protection motivation,
social upward comparison, combined, or control prototype). Participants were told that the
experiment’s purpose was to test a mobile stress-reduction application that provides progressive
muscle relaxation exercises to alleviate stress. They were instructed that the exercises had been
shown to reduce stress, but had never been included in an mHealth application design.
Participants were required to install the application and open it at least once to allow push
notifications. Once the prototype was installed and activated, they were told that use of the app
was not mandatory but welcome. We did not send out any push notifications during the first ten
days of the experiment to allow participants to familiarize themselves with the app. Over the
course of the ensuing weeks, the treatment groups received the push notifications according to
their prototype. All notifications were launched between 10 AM and 7 PM with at least one
night’s time between two notifications. All members of a treatment group were sent the same
notifications at the same time. The respective notifications in Online Appendix B were pushed
once per participant. In total, the control group did not receive any push notifications, whereas
each participant in the social upward comparison, protection motivation, and combined
treatment groups received 3, 6, and 9 push notifications, respectively. During the five-week
study period, we collected data on mHealth use with trace data from the prototypes. After the
experiment, participants completed a post-experimental survey. We evaluated the collected data
quantitatively and qualitatively. To further substantiate the nature of the interaction effects, we
finally conducted a vignette-based qualitative evaluation with n = 36 participants.
Measurement
Dependent Variables
We examined how the prototypes with various instantiations impacted the extent of mHealth
use. Extent of use is defined as the frequency of using a system and is a commonly used
measure of technology use [e.g. 12]. In our case, we measured extent of use by application
opening and training count. Specifically, application opening is measured as the number of
times a user opened the application. Training count is measured as the number of 3-minute
stress-reduction trainings that a user completed. After the five-week study period, we used
training count and application opening as objective measures of mHealth use.
Controls
We controlled for potential confounding variables through survey measures. First, we
controlled for social comparison orientation because individuals might differ in their
predisposition to engage in social comparison. Social comparison orientation is
a personal trait describing the extent to which people generally make comparisons about
their opinions, abilities, and general aspects of themselves [23]. Moreover, we controlled for
variables that are pronounced in rival theory, especially the health belief model. The health
belief model and protection motivation theory agree on the core constructs predicting
behavior change in the face of a health threat (i.e., threat severity and susceptibility,
response-efficacy, response costs, and self-efficacy) [48]. Research on the health belief
model, however, calls more intensively for including socio-demographic backgrounds and
especially education because individuals’ ability to deal with technology may influence how
they perceive health risks that are invoked through technology [3]. Thus, we control for
experience with mHealth as well as age, household income, and gender. We also control for
eHealth literacy, which assesses consumers’ perceived skills at using information technology
(IT) for health management [46]. Finally, we control for individuals’ perceived problems
with the health threat (i.e., stress) because the health belief model suggests that perceived
problems can constitute a particularly effective cue to action [48]. Online Appendix
A displays the scales and reliability measures.
532 SPOHRER ET AL.
Participants
A student sample was recruited for this study due to the prevalence of stress seen in this
population. Although often unduly dismissed, student samples can be a valuable source of
information if they fit with the general research goals [15]. While around two out of three
U.S. adults experience stress on a moderate to severe level daily, stress is becoming even
more prevalent in college students [8,9]. Studies regularly report elevated stress in a range
from 60 percent [35] to more than 75 percent [27] of college students. College students
experience a gain in autonomy entailing several stressors and demands that contribute to
these high numbers [27]. As such, many college students move away from home, leaving
family and friends; they have to learn to manage finances, cope with increased academic
workload and extracurricular activities, and need to make career choices [9,35]. mHealth
applications that help college students to alleviate stress are therefore in increasing
demand [27].
Participants were recruited from a bachelor’s course at a university in the United States.
They were offered 2.5 percent extra credit on their final grade in return for completing the
pre/post surveys and for installing and running the app on their Android or iOS smart
phone for the study period. Although our target was to obtain 30 participants per prototype,
we initially assigned 50 participants per prototype. We did so to achieve our target sample in
spite of some participants withdrawing from the study, or providing incomplete or unusable
responses. We excluded participants who failed to open the application at least once because
these participants did not expose themselves to the treatment.
The data from 138 participants was deemed usable and was analyzed to examine the
main and interaction effects of protection motivation and social upward comparison on the
two outcomes: application opening and training count. The participants were about equally
balanced regarding gender and age. There were no significant differences across the proto
type groups in terms of demographic characteristics, social comparison orientation,
mHealth experience, eHealth literacy, or perceived stress problems at the beginning of the
study period. Thus, we are confident that the variations in outcome variables are not caused
by systematic differences in demographics or predispositions across groups. Table 7 sum
marizes the demographics and pre-experimental measures.
Table 7. Descriptive characteristics and pre-experimental measures.

SUC PM SUC + PM Control Total
Descriptive n = 32 n = 35 n = 30 n = 41 n = 138
Statistics %/M n/SD %/M n/SD %/M n/SD %/M n/SD %/M n/SD P-Value Chi2/F
Age < 20 years 22% 7 23% 8 37% 11 20% 8 25% 34 .38 3.11
20-29 years 78% 25 77% 27 63% 19 80% 33 75% 104 .38 3.11
Male 47% 15 46% 16 43% 13 51% 21 47% 65 .92 0.48
INC < $ 20,000 25% 8 26% 9 27% 8 15% 6 22% 31 .61 4.5
$ 20,000-100,000 28% 9 31% 11 30% 9 22% 9 28% 38 .61 4.5
> $ 100,000 47% 15 43% 15 43% 13 63% 26 50% 69 .61 4.5
SCO 2.21 0.89 2.18 0.88 2.3 0.93 2.09 0.78 2.18 0.86 .77 0.37
EXP 1.14 1.39 1.21 1.66 1.47 1.64 1.02 1.58 1.19 1.56 .69 0.49
HLIT 5.43 0.73 5.48 0.63 5.67 0.87 5.45 0.97 5.50 0.82 .66 0.53
PROBL 3.88 1.79 4.28 2.01 4.37 1.99 3.80 1.93 4.07 1.93 .52 0.75
Notes: test of group differences; M, mean; n, number of participants; PM, protection motivation; SUC, social upward
comparison; SD, standard deviation; INC, household income; SCO, social comparison orientation; EXP, mHealth experience;
HLIT, e-health literacy; PROBL, problem perception of stress.
Manipulation Checks
We technically verified that the messages about protection motivation and social comparison
were pushed to the active view of participants’ smartphones and arrived as intended. Thus, it
was nearly impossible for participants to avoid this information. In the pre- and post-surveys,
we took several measures to ensure manipulation validity: First, we asked in the post-survey
whether the participants had received and read messages from the app during the experi
ment. All participants in the three treatment groups (n = 97) unanimously confirmed they
had received and read the messages, which was not the case for control group (n = 41)
participants, t(136) = 9.63, p < .001. Second, to ensure that the social comparison instantia
tions actually stimulated social upward comparison, all participants were asked to rate their
agreement1 with the statement “Other users used the health app much more often than I did”
in the post-survey. Participants who received social upward comparison treatment agreed
significantly more with the statement than participants who did not receive social compar
ison treatment (MSUC = 4.74, SDSUC = 1.45 vs. MNO_SUC = 4.25, SDNO_SUC = 1.24; z = -2.11, p
< .05). Third, to ensure the effectiveness of fear arousal through the protection motivation
instantiations, we assessed how much participants changed in their agreement1 with the
statement “I am scared about the prospect of getting stressed out by work” between pre- and
post-survey. There was no significant difference in agreement between the groups before the
study period (MProt.Mot = 3.72, SDProt.Mot = 1.78 vs. MNo_Prot.Mot = 3.97, SDNo_Prot.Mot = 1.61;
z = .86, p > .05). After the study period, participants who had received protection motivation
treatment showed increased agreement, whereas participants who had not received protec
tion motivation treatment showed lower agreement than before (MProt.Mot = 4.05, SDProt.Mot
= 1.66 vs. MNo_Prot.Mot = 3.75, SDNo_Prot.Mot = 1.55). A one-tailed z-test showed that the
difference in change was significant, z = -1.76, p < .05.
Evaluation Results
Effects on mHealth Use
We ran full factorial two-way analyses of variance (ANOVA) on the sample of 138
participants to examine the presence of interaction effects of protection motivation and
social upward comparison on the two mHealth use outcomes (training count and applica
tion opening). Once the interaction effect was established, we conducted simple main effects
analyses to examine the isolated effects of protection motivation and social upward
comparison without mutual interference by drawing on the subsamples that had received
no protection motivation treatment (n = 73) and no social upward comparison treatment
(n = 76), respectively. We ran analyses of covariance (ANCOVA) for all models to see
whether the results were robust in the presence of control variables. Table 8 displays the
different means and standard deviations, Table 9 displays the corresponding results of
ANOVA, ANCOVA, and simple main effects analyses.
Training Count
We found a significant negative interaction effect between protection motivation and social
upward comparison on training count (Table 9 M1). The interaction effect remained
significant and only increased in effect size in the presence of control variables (Table 9
M2). Simple main effects analyses showed that protection motivation had a significant,
534 SPOHRER ET AL.
Table 8. Training count and application opening by prototype group.

Training Count Application Opening
Protection Motivation Protection Motivation
Social Upward Comparison No PM PM Social Upward Comparison No PM PM
No SUC n = 41 n = 35 No SUC n = 41 n = 35
M = 1.83 M = 2.46 M = 4.98 M = 7.09
SD = 1.00 SD = 1.58 SD = 2.82 SD = 4.45
SUC n = 32 n = 30 SUC n = 32 n = 30
M = 4.88 M = 3.47 M = 10.09 M = 8.33
SD = 4.46 SD = 3.34 SD = 8.94 SD = 7.80
Notes: M, mean; n, number of participants; PM, protection motivation; SUC, social upward comparison; SD, standard
deviation.
Table 9. ANOVA, ANCOVA, and analysis of simple main effects.

Training Count Application Opening
Source F df ηp2 F df ηp 2 F df ηp 2 F df ηp2
Overall sample Model M1 Model M2 Model M7 Model M8
SUC*PM 4.44* 1 .03 4.88* 1 .04 3.26† 1 .02 3.07† 1 .02
SUC 17.63*** 1 .12 17.05*** 1 .12 8.83** 1 .06 8.18** 1 .06
PM 0.65 1 .01 0.94 1 .01 0.03 1 .00 0.00 1 .00
Gender 0.27 1 .00 0.04 1 .00
INC 0.76 2 .01 0.19 2 .00
Age 1.1 1 .01 0.46 1 .00
SCO 0.37 1 .00 0.23 1 .00
EXP 0.08 1 .00 0.19 1 .00
HLIT 0.31 1 .00 2.29 1 .02
PROBL 2.79 1 .02 1.75 1 .01
No SUC Model M3 Model M4 Model M9 Model M10
PM 4.42* 1 .06 4.15* 1 .06 6.29* 1 .08 5.54* 1 .08
Gender 0.28 1 .00 1.63 1 .02
INC 1.05 2 .03 0.05 2 .00
Age 1.46 1 .02 0.25 1 .00
SCO 0.03 1 .00 1.25 1 .02
EXP 0.59 1 .01 0.02 1 .00
HLIT 0.59 1 .01 0.64 1 .01
PROBL 1.73 1 .03 0.17 1 .00
No PM Model M5 Model M6 Model M11 Model M12
SUC 18.06*** 1 .20 15.61*** 1 .20 11.96*** 1 .14 9.71** 1 .13
Gender 0.06 1 .00 0.03 1 .00
INC 0.09 2 .00 0.03 2 .00
Age 4.27* 1 .06 3.5† 1 .05
SCO 0.58 1 .01 2.96† 1 .04
EXP 0.29 1 .00 1.42 1 .02
HLIT 0.18 1 .00 0.05 1 .00
PROBL 0.49 1 .01 0.35 1 .01
Notes: †p <.1; *p < .05; **p < .01; ***p < .001; effect sizes ηp2 ≥ .14 are large, ηp2 ≥ .06 are moderate. PM, protection
motivation; SUC, social upward comparison; INC, household income; SCO, social comparison orientation; EXP, mHealth
experience; HLIT, e-health literacy; PROBL, problem perception of stress.
medium sized positive effect on training count when social upward comparison was not
present (Table 9 M3), but protection motivation did not have a significant effect on training
count when social upward comparison was present (F(1,60) = .96, p > .1, ηp2 = .03).
Similarly, social upward comparison had a large, significant positive effect on training
Figure 2. Visualization of Simple Main Effects. PM, protection motivation; SUC, social upward comparison.
count when protection motivation was not present (Table 9 M5) but only a small, non-
significant effect when protection motivation was present (F(1,63) = 2.54, p > .1, ηp2 = .04).
Figure 2 illustrates the simple main effects. All effects remained stable with control variables
as covariates (Table 9 M4 & M6).
Application Opening
The negative interaction effect of protection motivation and social upward comparison on
application opening was only borderline significant (F(1,134) = 3.26, p < .1, ηp2 = .02, Table 9
M7) and remained so in light of control variables (Table 9 M8). According to simple main
effects analyses, protection motivation had a significant, medium sized positive effect on
application opening when social upward comparison was not present (Table 9 M9) but only
a small, non-significant effect when social upward comparison was present (F(1,60) = 0.68,
p > .1, ηp2 = .01). Social upward comparison had a large, significant positive effect in the
absence of protection motivation (Table 9 M11) but none when protection motivation was
present (F(1,63) = 0.65, p > .1, ηp2 = .01). Control variables did not qualitatively change these
results (Table 9 M10 & M12).
These results provided support for our hypotheses. Simple main effects analyses showed
that both protection motivation and social upward comparison have positive effects on
mHealth use when they are applied in isolation, thus providing support for H1 and H2. The
groups using different prototypes differed significantly in their use of the artifact. In line
with H3, the results demonstrated a negative interaction effect between protection motiva
tion and social upward comparison. Both protection motivation and social upward com
parison showed lower effect sizes and less significant effects when combined with the
respective other mechanism. In fact, participants provided with the combined prototype
used the artifact less frequently than participants provided with the social upward compar
ison prototype. As displayed in Table 8, social upward comparison resulted in the most
mHealth use, followed by combined social upward comparison and protection motivation,
protection motivation, and control conditions.
536 SPOHRER ET AL.
Post-Hoc Analysis
In the scope of the post-experimental survey, we asked and evaluated open-ended ques
tions. Specifically, we asked the participants what they liked and disliked about the applica
tion (FB1-FB3 in Online Appendix A). As we were interested in the negative interaction
effect, we examined all comments that related directly to the developed design features or
their consequences (i.e., notifications, the different views described in the Theory-Guided
Instantiation section, social comparison, or protection motivation) and compared negative
to positive and neutral comments. Two authors independently coded the free text answers
as either negative valence (-1) or neutral/positive valence (0). Cohen’s Kappa was .78 and
initial disagreements about single codes were quickly resolved through discussion between
the coders. Online Appendix D provides exemplary quotes. We then compared the relation
of negative to positive/neutral comments across the treatment and control groups. A Chi-
squared test was significant, Χ2(6,138) = 21.292, p < .01 (Table 10). The group with the
combined protection motivation and social upward comparison prototype was significantly
more likely to report negative feedback than users of the control prototype and users of the
prototypes that instantiated one theory only.
Some participants directly verbalized the negative interaction between protection moti
vation and social upward comparison that we hypothesized. For example, the following
quote of a participant who used the combined prototype illustrates the conflict between
wanting to cope with a personal health threat while simultaneously receiving information
about a social threat. The participant said:
I did not enjoy the pop-up notifications that said, ‘others are using the application more than
you.’ These gave me a negative feeling and made me less likely to want to use the application
because it became about competition and not bettering myself.
Qualitative Substantiation
Having statistically established the hypothesized effects of our instantiations under experi
mental conditions, we aimed to further substantiate the effects and to reduce concerns
about their potential cultural specificity. Thus, we recruited a sample of n = 36 students at
a university in Central Europe for a vignette-based qualitative evaluation. The participants
(aged 23-29 years, 23 female, 13 male) were invited to a personal meeting with an average
duration 45 minutes in which they received a vignette that led them through interactions
with one of the treatment prototypes (i.e., the protection motivation prototype, the social
upward comparison prototype, or the combined prototype). Each of the three prototypes
was received by n = 12 participants. The participants went through the vignette on their
Table 10. Relative feedback valence frequencies by experiment

group.
Negative (-1) Neutral/Positive (0)
PM 2.9% 97.1%
SUC 9.4% 90.6%
Combined PM+SUC 20% 80%
Control 0% 100%
Χ2(6, n = 138) = 21.292, p < 0.01
Notes: PM, protection motivation; SUC, social upward comparison.
own but were supported by a research assistant if they had questions or needed help. The
vignette entailed several push notifications according to the prototype (see Online
Appendix B) and participants with social comparison or combined prototypes were addi
tionally pointed to the performance view. Subsequently, each participant was interviewed
following a semi-structured interview guide (Online Appendix E). The interviews were
coded for perceived effects of the different design features.
The participants broadly confirmed the positive motivational effects of protection moti
vation and social upward comparison in isolation (Online Appendix E provides exemplary
quotes). Specifically, in the groups faced with prototypes that instantiated social upward
comparison or protection motivation in isolation, there were no statements that reported
perceived negative effects on the motivation to use the mHealth app that were associated
only with the fear appeal messages (i.e., the protection motivation design feature) or with
the combination of the performance visibility page and the social upward comparison
messages (i.e., the social upward comparison design features). In contrast, participants
who were confronted with the combined design features of protection motivation and
social upward comparison elaborated on a number of negative perceptions. The perceived
negative effects matched the negative interaction effects of social upward comparison and
protection motivation that we theorized. First, statements referred to perceptions of con
flicting threats namely, a health threat through fear appeal messages and a social threat
through social upward comparison. Second, participants perceived that the dynamic infor
mation that allowed for social upward comparison was at odds with the static nature of fear
appeal messages (Online Appendix E provides exemplary quotes). Overall, the picture
painted by the qualitative substantiation in Europe was in line with the experimental results
from the United States. The interviews lent further support to our reasoning on the negative
interaction effect.
Discussion
Contemporary mHealth research and practice often implement piecemeal combinations of
several behavior change techniques [16, 36, 43]. We show that it is important to consider the
theoretical mechanisms underlying behavior change techniques instead of equipping
mHealth with a simple combination of popular techniques. The results of our study
illustrate that the widely applied techniques of protection motivation and social upward
comparison negatively interacted to influence mHealth use. Engaging in explanatory design
theorizing, we inscribed kernel theories into an artifact and evaluated the interdependence
of simultaneously implemented design features [45, 47]. This allowed us to theorize about
and test direct and interaction effects of protection motivation and social upward compar
ison on mHealth use. We tested these effects through a field experiment and substantiated
the reasoning qualitatively.
Theoretical Contributions
This study contributes to academic IS literature in three key ways. First, we theorize and
empirically demonstrate negative interaction effects between the mechanisms of two pro
minent behavior change theories, namely, social upward comparison and protection
538 SPOHRER ET AL.
motivation theory, and their effect on mHealth use. We theorized that this negative
interaction occurs because the mechanisms underlying the theories yield fundamentally
different types of threats and perceptions of one’s abilities to overcome the threat.
Experimental and qualitative results support this reasoning. Our findings thereby elicit
mutual boundary conditions for protection motivation and social upward comparison
theory. When mechanisms of one are present, they can restrict the effectiveness of the
other. These findings resonate with prior work that suggested social mechanisms could
influence the formation of fear and the effectiveness of fear-based campaigns [10]. Future
work can build on these results to provide more comprehensive models of the relationship
between health threat perceptions and social upward comparison to determine when each
one is actually appropriate and when it is not.
Second, we contribute to research on behavior change techniques and their mechan
isms of action [13,30] by showing that a combination of behavior change techniques does
not always result in synergistic effects. In fact, combinations of behavior change techni
ques can result in outcomes that are worse than the outcome of the techniques in
isolation. In our study, mHealth use was actually lower if participants dealt with simulta
neous instantiations of protection motivation and social upward comparison theory than
if they dealt with social upward comparison alone. This finding calls previously assumed
synergistic effects in mHealth research and practice [16, 17, 36] into question. Thus,
rather than focusing on behavior change techniques, more research should focus on the
potentially conflicting theoretical mechanisms underlying them and their boundary con
ditions. In a broader picture, our results suggest that the commonly recommended focus
on behavior change techniques as a unit of analysis [16, 36] could have detrimental
consequences for mHealth research in general. It could disconnect the unit of analysis
from underlying causal mechanisms, obfuscate individual effects, and prevent the identi
fication of boundary conditions and possible incommensurability. Future research may
thus need to treat the concept of behavior change techniques more cautiously and better
account for the causal mechanisms and theoretical frameworks in which they are
embedded.
Third, we contribute to the design knowledge in mHealth with explanatory design
theorizing about the effects of social upward comparison and protection motivation on
mHealth use. In doing so, we instantiated the theories in design features, conducted
a rigorous evaluation in the stress alleviation domain, and illustrated the main and inter
action effects of the instantiations. The presented generic blueprints for instantiating
protection motivation and social upward comparison in mHealth are based on elementary
smartphone features and can be reused in other mHealth domains. The tested hypotheses
and instantiations can jointly be regarded as a mid-range theory of the design of mHealth
artifacts [34, 45]. In providing one of few IS examples of explanatory design theorizing [47,
56], we finally draw attention to the role of purposefully developing new IT in order to build
knowledge about theoretical mechanisms that influence human behavior with IT. Our study
shows that explanatory design theorizing can help understand context-specific effects of
established theoretical mechanisms and refine associated kernel theories. We propose that
more IS research can utilize this method to better understand how combinations of design
features can interact to impact use and behavior.
Practical Contributions
Our research informs practitioner communities and is important for mHealth developers.
First and foremost, our study suggests that mHealth designers should be very careful when
combining features of different behavior change techniques within one artifact. The com
monly held assumption that combinations of two beneficial behavior change techniques
should have additive or even complementary beneficial effects does not stand up to scrutiny.
We demonstrated that popular behavior change techniques belonging to theories of protec
tion motivation and social upward comparison theories had mentionable negative interac
tion effects. Adverse user reactions created through such interaction effects can constitute
a major risk to the success of a software product [38]. Where available, developers should
draw on behavior change techniques from the same theory or from theories building on
commensurate mechanisms. It is an important task for future research to create theory-
driven collections of commensurate techniques that go beyond the established rough
taxonomic classifications [17, 42] and account for the alignment of underlying theoretical
mechanisms.
Moreover, we show that it is promising to leverage mHealth use through anonymous
social upward comparison. Our finding reduces the pressure on mHealth developers to
create network effects based on their users’ extant relationship networks. As such, conven
tional knowledge on social influence in IS adoption would suggest that mHealth providers
need to attract many users whose opinions are important to each other, such as friends [64].
Our findings show that mHealth developers can instead provide users with opportunities
for anonymous social upward comparison, which is much easier to achieve. We demon
strated that this is technically feasible and that it fits with the context of mHealth where
privacy and anonymous social influence can be attractive [6, 59].
Additionally, characterizing and implementing effective mechanisms to leverage use in
mHealth is valuable for physicians, developers, and other practitioners who currently have
little guidance regarding what to base their recommendations of mHealth on [16, 50]. Our
results indicate that the inclusion of social upward comparison leverages more use than
protection motivation. Additionally, because we found a negative interaction effect between
social upward comparison and protection motivation, it is not advisable to integrate both
theoretical mechanisms into a single mobile application, but rather choose one over the
other. The results demonstrated that protection motivation has an effect on use when social
upward comparison is not present. Therefore, fear appeals are still feasible for increasing
use of mHealth and can be easily communicated to end-users through a push notification.
However, future research should investigate when one is more appropriate than the other.
Study Limitations and Future Research

We conducted explanatory design theorizing and leveraged the advantages of a randomized
field experiment, which comes with some limitations. First, the generalizability of our
results depends partly on the representativeness of our sample. We evaluated our artifact
using a student sample, which is appropriate if clearly articulated and justified [15].
A student sample actually matched our research goals because stress constitutes
a tremendous issue in college students [8, 9, 27]. The sample of our main experiment
consisted of U.S. students and a qualitative substantiation was conducted with European
540 SPOHRER ET AL.
students, which reduces potential concerns about culture-specific effects. However, not all
characteristics of college students may transfer to other social groups (e.g., a relatively high
eHealth literacy). Consequently, our work should be replicated in other demographic,
cultural, and occupational contexts, including high-stress environments, to increase the
generalizability of results. Likewise, future work can test the effects of the instantiations in
other mHealth contexts than stress alleviation.
Second, the development of our design features aimed to maximize the faithfulness of
theory instantiation rather than maximizing the effect on mHealth use. We acknowledge
that different push messages could have stronger effects on use. In line with guidelines for
explanatory design theorizing [45] and our study’s goal to evaluate theoretical effects,
however, we deemed it crucial to develop design features that validly represent the focal
theoretical mechanisms without risking potential interferences through other mechanisms.
Accordingly, we tailored features that are intentionally basic beyond the coverage of the
kernel theories. Thus, our fear appeals focus only on statements that implement threat
appraisals (threat severity and susceptibility) and coping appraisals (response-efficacy, self-
efficacy, response costs) according to protection motivation theory; our social upward
comparison features focus only on defining mHealth use as a comparison dimension,
emphasizing a negative performance discrepancy, and preventing common side effects
according to social upward comparison theory. Future research can build on our results
to tailor more complex messages and visual designs that have stronger effects on mHealth
use but needs to account for potential interaction effects with other behavior change
mechanisms.
Third, our treatment and control groups differed in the number of push notifications
they received. Some proportion of the main effects could therefore stem from the mere
presence of more notifications. Given that correlations of mHealth use with the number of
received notifications were not significant and all manipulation checks were successful, we
are confident that the difference in notifications did not strongly impact our findings.
Nonetheless, future research may replicate our results while including placebo messages
to ensure equal numbers of notifications across treatment and control groups.
Finally, we measured mHealth use objectively by collecting data using a web-based
backend system that tracks usage frequency to the level of single health exercises and
application openings. Such an objective measure is useful for capturing the extent to
which a system is used. However, research has also suggested richer use conceptualizations.
For example, the breadth of use (number of features used) or variety of use (the extent to
which a system is used to carry out different tasks) [12]. Future research can build on our
work by including such different conceptualizations of use.
Conclusion
Contemporary mHealth often combines behavior change techniques without sufficiently
considering the underlying theoretical mechanisms. We proposed that combining behavior
change techniques does not always result in synergies and improved user behaviors. We
tested these ideas drawing on theories of social upward comparison and protection motiva
tion. We engaged in explanatory design theorizing, including theory instantiation, artifact
development, and testing in a field experiment. The results show that protection motivation
and social upward comparison negatively interacted to impact mHealth use, rendering their
combination less effective. We suggest that this effect occurs because the theoretical
mechanisms underlying the instantiations yield different types of threats and counteracting
appraisals of one’s abilities. Our findings imply that mHealth developers need to be careful
when combining features from different behavior change techniques within one mHealth
application. Where available, developers should draw on behavior change techniques that
stem from the same theory and build on commensurate mechanisms. Otherwise, they could
inadvertently influence users to engage less frequently with their mHealth application.
Notes
1. 7-point scale (strongly disagree—strongly agree).
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About the Authors

Kai Spohrer is an Assistant Professor at the Department of General Management and Information
Systems of the University of Mannheim, Germany. He received his Ph.D. in Information Systems
from that university. Dr. Spohrer’s research aims to understand and improve the development and
use of information systems, especially in the domains of health IT, blockchain systems, and software
engineering. His papers have appeared or are forthcoming in Information Systems Research, IEEE
Transactions of Software Engineering, Information Systems Journal, and other venues.
Monica Fallon received her M.A. in Psychology from the University of Arizona. She is a doctoral
student at the Department of General Management and Information Systems at the University of
Mannheim. Her research has appeared in major international Information Systems conferences and
in the leading Psychology journals. Her research focuses on how digital technologies can be used to
support health behavior change and to better understand acute stress responses.
Hartmut Hoehle is a Professor and Chair of Enterprise Systems at the University of Mannheim,
Germany. He received a Ph.D. in Information Systems from Victoria University of Wellington, New
Zealand. Dr. Hoehle’s research interests include the design, implementation, and use of enterprise
systems.. Stemming from his professional experiences gained while working at Deutsche Bank, he is
particularly interested in how services and products can be distributed through electronically
mediated channels. His work has appeared or is forthcoming in MIS Quarterly, European Journal
of Information Systems, Decision Support Systems, International Journal of Operations & Production
Management, and other journals.
Armin Heinzl is a Professor and Chair of General Management and Information Systems at the
University of Mannheim, Germany. He received his doctoral degree and habilitation from the
Koblenz Corporate School of Management, Germany. He was a professor at the University of
Bayreuth and has held visiting positions at Harvard, Berkeley, Irvine, ESSEC, LSE, and USI
Lugano. Dr. Heinzl’s research interests focus on digital innovation, particularly the design of
mHealth applications, the design of anthropomorphic systems, agile development practices, the
impact of artificial intelligence, innovation strategies in digital platforms, and the management of
digital innovations. His research has appeared in MIS Quarterly, Information Systems Research,
Journal of the Association of Information Systems, IEEE Transactions on Engineering Management,
IEEE Transactions on Software Engineering, and other journals.

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Designing Effective Mobile Health Apps: Does

Kai Spohrer, Monica Fallon, Hartmut Hoehle & Armin Heinzl

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Designing Effective Mobile Health Apps: Does Combining

Questionable Assumptions in mHealth

Table 1. Behavior change techniques and behavior change theory in mHealth.

Social Upward Comparison Theory

Protection Motivation Theory

Research Method: Explanatory Design Theorizing

Table 2. Design science approach: Explanatory design theorizing.

combination. In the Hypotheses Development section, we then hypothesize beneficial main

Table 3. Social upward comparison.

Table 4. Protection motivation: Theoretical dimensions, principles, and features.

Hypothesis 2 (H2): The protection motivation instantiation has a positive effect on

Hypothesis 3 (H3): Combined instantiations of protection motivation and social upward

mHealth Domain: Alleviating Stress

Prototyping and Artifact Development

Table 5. Baseline features (all participants had these features).

Training View Information View

Table 6. Experimental design with prototype features.

Table 7. Descriptive characteristics and pre-experimental measures.

Table 8. Training count and application opening by prototype group.

Table 9. ANOVA, ANCOVA, and analysis of simple main effects.

Table 10. Relative feedback valence frequencies by experiment

Study Limitations and Future Research

About the Authors

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