Better GI
A comprehensive self-management Intervention addressing anxiety & depression among persons with Irritable Bowel Syndrome.
Background
9-17% of individuals in the US have a diagnosis of irritable bowel syndrome (IBS). That’s a lot of people, and there is a good chance that someone you know also has IBS.
IBS is a disorder of brain-gut interaction and associated with recurrent abdominal pain​.
Around 50% of individuals with IBS also have co-morbid anxiety and/or depression.
Report: National Library of Medicine
Problem
The Comprehensive Self-Management (CSM) intervention was developed to improve quality of life and reduce abdominal pain. The CSM had been disseminated through a 230 page book, which providers could use with their patients. Yet intervention uptake has been limited.​
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Time
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Complexity
Solution
A 9 week self guided mobile app for IBS patients.
Patient Recruitment
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Study information posted on the University of Washington Institute of Translational Health Sciences
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ResearchMatch, national health volunteer registry
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Ages 18-70
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Met IBS criteria and have diagnosis from healthcare provider
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Moderate to severe anxiety and/or depression
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Excluded if they had multiple red flag symptoms
Provider Recruitment
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Primary care clinics: WWAMI region Practice and Research Network (WPRN)
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Gastroenterologists: convenience sampling
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Cared for at least 3 IBS patients per month
Card Sorting
Usability Issues
Paper-based
In the original CSM intervention, the content is presented as a written workbook and taught during in-person sessions.
Because access to skill demonstrations was limited to a synchronous approach, users were unable to review skill demonstrations at their own pace and were frustrated with the intervention.
Check-ins
The original CSM intervention was designed for skills and information to be primarily delivered during in-person sessions.
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While individuals appreciated having a knowledgeable professional, they preferred to process information independently and have brief check-ins to assess if they absorbed and applied the content.
Provider feedback
The CSM intervention lacks mechanisms for clinicians to be aware of client progress, and so they are unable to notice and adapt when treatment is unsuccessful for a patient.
Delivery
The original CSM intervention was designed for in-person delivery by clinicians, and typically takes more time than they have during visits. Clinicians report limited time available during clinic visits (<10 min) to deliver content.
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As a result content was skipped or rushed, or the intervention was abandoned all together.
Key Findings
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Patients and providers liked the structure and accountability of the intervention.
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Patients were interested in moving through the manual at their own pace, but still have a professional to check-in with for questions.
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Patients identified main challenges as: lack of time to complete the daily assignments, lack of motivation and other personal obstacles.
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Providers identified their main challenge: lack of time to do weekly teaching sessions.
Design & Build
Redesign Goals
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Reduce the face-to-face time required by providers to increase the likelihood that the intervention is incorporated into their practice.
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Make the intervention content more digestible to improve uptake and reach.
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Make the tracking (food, sleep, symptoms) required by the intervention easier to do.
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Create content summarizing patient behavior to facilitate communication with their provider when they meet.
App Requirements
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Onboard the user to the intervention.
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Simplify content and focus on making learning the skills and tracking easy.
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Provide insights/data about the relationship between the user’s behavior and symptoms.
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Provide motivation to keep the users engaged for the length of the intervention.
Miro
Miro is a online collaborative digital white board which we used for many activities.
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Refining the content in the original manual, and collecting graphics and videos to vary content delivery and reduce the amount that needs to be read
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Collecting examples of other similar apps as inspiration for the look and feel of our app
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Working on the information architecture and task flows that need to be included in the app
We also hired an illustrator to draw out pictures to go along with the content in the manual.
User Testing
Our next step was to build out a prototype of our concept for user testing.
The benefits of prototyping before building an app is that it gives your users a very realistic example of what the app would look like and how they would interact with it and you don’t spend a lot of money or time before you get validation that you are on the right track
User Testing
Over 10 days we tested the onboarding sequence and first 3 modules using a working prototype.
Recruitment:
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Contacted 8 previous participants who were interviewed about the original intervention and 7 agreed to work with us
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The only person who didn’t agree wasn’t interested in an intervention but was hoping for a medication
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In addition to those original 7 we also recruited an 8th participant from word of mouth who met our needs of hearing from somebody who was male and relatively new to their IBS diagnosis.
Insights & Findings
Onboarding
For a paced intervention, content needs to be very clear. Onboarding plays a really important role in letting the user know:
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Expectations for how they will be interacting with the app.
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The pace of the program and how to navigate the intervention content.
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How it benefits them (What do they get out of it??).
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That it is designed to help manage symptoms and doesn’t replace seeing a provider.
Modules
When we asked users about the content two things came up for us to revisit:
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Emphasize why each module is beneficial to understand and manage symptoms. 
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Pacing the users: More seasoned IBS patients asked for modules to be unlocked so they could skip ahead, or jump to modules that interested them. 
Overall, users were more engaged by the content and and liked the length of the modules.
Tracking
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Participants were the most excited about being able to track in-app and being able to look at compiled data
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Users would like to track more physical, mental and trigger food symptoms than we originally offered.
Reports
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Users want reports that they can share with their healthcare provider.
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Generally, users were happy with daily symptom and food reports, but would like personalized insights from tracking. For example, insights encouraging/discouraging certain food items
or practices.
Skills
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Most users thought it was reasonable to do a daily 5-15 minute skill practice.
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We discovered that users wanted the ability to check off the skills and types tracking they completed that day.
Next Steps
Mobile App
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Develop content for additional optional modules.
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Incorporate the feedback from the user testing to update the design (dashboard, reports etc.) and content language/tone.
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Develop the logic needed for the app to produce insights regarding connections between their behavior and symptoms experienced.
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Build out all the app screens to give to a developer.
Academic
Grant Proposal, R34, submission to NIMH:
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To develop implementation study and build and pilot the app.​
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Publications:
Kamp K, Yang PL, Friedman E, Lopez A, Iribarren S, Barney P, Munson S, Heitkemper M, Levy R. Formative Evaluation of a Comprehensive Self-Management Intervention for Irritable Bowel Syndrome, Comorbid Anxiety, and Depression: Mixed Methods Study. JMIR Form Res. 2024 Jan 31;8:e43286. doi: 10.2196/43286. PubMed PMID: 38294871; PubMed Central PMCID: PMC10867748.​​
Success Reviews
“All that together I think, packaging evidence-based tools in an easy to access way, is likely to be helpful to people.”
“I honestly think this was a cool app. I enjoyed the few days I had with it and I’ve never seen anything like it or anything tailored toward IBS. It’s a pretty amazing thing. I would love to try itonce it’s built with all of the modules."
“I do like that it [app] was made easy. If I can figure it out, anyone can figure it out.”
“Email me when it is out, I’ll be a user.”