Mobile health apps for low income communities

Mobile Health Applications for Low Socio-Economic Communities
July 2011

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Project Overview
Applications for Good (A4G) asked Detecon to assess how mobile applications can be leveraged to alleviate obesity-related health issues in underserved communities.
Overview
Objective
Evaluate how mobile applications can be leveraged to positively impact obesity-related health issues most acutely felt by low-income and minority communities.
Approach
Market Overview & Preliminary Gap Analysis
Do mobile applications hold potential as a tool for positive health intervention?
How can mobile apps be leveraged to combat obesity-related health issues?
What apps are currently available to address prevention and remediation of obesity-related health problems? How comprehensive are they?
How well do the available offerings meet the unique needs of A4G’s target population? Where are the gaps?
Potential Next Steps for A4G
How can A4G help drive the development of applications that cater to the unique circumstances and needs of its target population?
How can A4G play a role in furthering the study of its constituents’ needs and the efficacy of targeted mobile app interventions?
What can A4G do to facilitate successful launch and post-launch consumer uptake of health-focused apps, particularly with regard to marketing, partnerships and monetization?
Duration
2 weeks (July 2011)
Background
Applications for Good (A4G), an initiative of One Economy, seeks to support the development of applications that provide social benefit, particularly for communities of low socio-economic status (SES).
Detecon is a global consulting company which unites classic management consulting with a high level of information and telecommunication technology expertise.
Serving telecommunications and industry clients around the world, the San Francisco-based Detecon, Inc. team includes experts in the field of telecommunications strategy & innovation and mobile internet products &services.

Management Summary
Mobile apps hold significant promise for positive health interventions, but ensuring that the potential benefits are accessible to and realized by Americans of low socio-economic status (SES) remains a challenge.
Management Summary
Smartphone ownership among minority and low-income segments of the population is already more substantial than one might assume and rates are fast increasing.
Android is particularly popular among low SES users making it a logical platform choice for developing applications targeted to this market segment.
Research into the efficacy of mobile technology in tackling obesity and other medical conditions is still very early stage. However, preliminary results are encouraging and suggest there is significant potential to induce and support ongoing behavioral change.
The versatility of mobile applications holds additional potential as they can be used for a variety of purposes, including education, facilitating access, aiding ongoing monitoring and intervening in users’ daily routines.
We expect that app features will continue to expand to create more customizable, robust, social and fun user experiences.
New sensor technology and algorithms may facilitate advanced and predictive intervention models to help users stay on track and reap long-term health benefits.
A4G’s target population faces a unique set of multi-faceted challenges, including lower rates of literacy, numeracy and access to resources. While existing applications can address some of their needs, there is a dearth of applications targeted to the unique circumstances of low SES communities.
There is an opportunity to create apps that leverage public data and enable low SES communities to more easily access health and nutrition resources.
Superior design and visualization techniques will also expand the appeal and potential benefits of mobile health apps to low literacy and numeracy populations.
There is also an opportunity for A4G to broker collaborative efforts among researchers, nonprofits and corporations to develop, promote and distribute applications designed to impact health outcomes among low SES communities.

Contents
1
Obesity and Nutrition in America
2
Low SES Communities and Mobile Technology
3
Mobile Applications as a Health Enabler
4
Mobile Health Apps Overview
5
Preliminary Gap Analysis
6
Conclusions & Next Steps
7
Appendix

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1. Obesity and Nutrition in America
Obesity has rapidly developed into a major health issue in the United States, affecting virtually all parts of the country and nearly a third of the adult population.
Obesity Trend Amongst US Adults (1990 – 2009)
The CDC defines a person as obese if they have a BMI greater than or equal to 30 (roughly 30 lbs overweight for a 5’4” person).
In 1990, among states participating in the Behavioral Risk Factor Surveillance System, ten states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%.
In 2009, only one state (Colorado) and the District of Columbia had a prevalence of obesity less than 20%. Thirty-three states had a prevalence equal to or greater than 25%; nine of these states had a prevalence of obesity equal to or greater than 30%.
Source: Behavioral Risk Factor Surveillance System, CDC

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The target audience for A4G anti-obesity initiatives are Americans of low SES. Higher obesity rates among this population are due to a variety of complex factors.
US Obesity Rate by Income
US Obesity Rate by Education
US Poverty Rate by Ethnicity
33.8%
32.8%
25.8%
25.3%
31.8%
30.4%
29.6%
29.7%
29.5%
24.6%
21.5%
9.4%
>$50k
$35k-$50k
$25k-$35k
$15k-$25k
<$15k
Some college
High school graduate only
Did not graduate high school
College grad
African American
White
Hispanic
Low-income individuals are less likely to have access to affordable, nutritious food.
Lower levels of education are associated with both lower SES and poorer understanding of health and nutrition.
Poverty is significantly more prevalent among African American and Hispanic communities.
US Adult Obesity Rate by Ethnicity
US Childhood Obesity Rate by Ethnicity
African American
African American
35.7%
23.9%
Hispanic
28.7%
Hispanic
23.4%
White
23.7%
White
13.0%
Sources: US Census Bureau 2010; CDC 2011; JAMA 2010; The Trust for America's Health and the Robert Wood Johnson Foundation, 2011

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The recession has exacerbated the hardships faced by many lower SES communities with nearly one in seven Americans now relying on food stamps for their meals.
About S.N.A.P.
S.N.A.P. Redemptions by Firm Type
The Supplementary Nutrition Assistance Program (S.N.A.P.) is popularly referred to as “food stamp program”
Administered by the U.S. Department of Agriculture
As of June 2009, the average monthly benefit was $133.12 per person
As of May 2011, 44 million Americans get a portion of their meals using food stamps
To be eligible, recipients have to have near-poverty level incomes
8.4%
Supermarket
3.9%
4.2%
Superstore
48.9%
Large/Medium Grocery Store
Convenience Store
34.6%
Other
S.N.A.P. and Quality of Diet
“Food Stamp participants were less likely to consume fruits or vegetables than nonparticipants.”
“Over half of all foods consumed by Food Stamp participants came from foods that should be consumed only occasionally.”
“Food Stamp participants were less likely to have adequate intake of vitamins and minerals than higher income individuals.”
The current economic climate has pushed more Americans into relying on food stamps for their meals.
Food stamp usage is typically at supermarkets, superstores and convenience stores which partially impacts dietary quality.
Sources: US Department of Agriculture, 2011; Diet Quality of Americans by Food Stamp Participants, July 2008; S.N.A.P. Benefit Redemption Division Annual Report 2010

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In response to the growing obesity problem, several initiatives have been launched to promote healthy lifestyles, especially among communities of low SES.
“Let’s Move” Campaign
Healthy Incentives Pilot (HIP) Program
Pilot program ongoing in Hampden County, Massachusetts
Hampden County is a mix of twenty-seven urban, suburban and rural cities and towns and approximately 50,000 SNAP households
Objective is to rigorously evaluate the impact of financial incentives provided at point-of-sale for the purchase of fruits, vegetables and other healthy foods on the diet of SNAP participants
Funded by a $20 million grant in the US Farm Bill of 2008
Campaign to end childhood obesity in the United States
Launched by First Lady, Michelle Obama on February 9, 2010
Key components include:
Eating healthier
Being more active
Labeling foods better

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The high prevalence of obesity among low SES communities has made obesity a significant contributor to Medicaid expenses nationwide.
Adult Obesity Attributable Medical Expenses
Adult Obesity Attributable Medicaid Expenses (2003)
In 2003, adult obesity resulted in an estimated $75 billion of medical expenses.
In 2008, all obesity-related medical expenses were estimated at $140 billion.
Indiana
15.7%
Delaware
13.8%
Arizona
13.5%
12.9%
Louisiana
12.9%
Maryland
New York
8.5%
Wyoming
8.5%
Alaska
8.2%
All figures in million dollars (2003 dollars)
Massachusetts
7.8%
7.7%
Rhode Island
Sources: RTI, CDC

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Appendix

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2. Low SES Communities and Mobile Technology
Ubiquitous wireless connectivity and growing smartphone penetration makes mobile a key potential tool in addressing the needs of low SES communities.
US Smartphone Penetration
US Wireless Penetration
US wireless subscribers in millions (% of population)
Smartphones
Other Phones
63%
67%
68%
303(96%)
208(69%)
+4%
110(38%)
37%
33%
32%
34(13%)
2011*
2010*
2009
2010
2005
2000
1995
Wireless technology usage is now ubiquitous in the US and reaches almost every American.
Smartphone penetration is growing rapidly and this year is estimated to grow by 4 percentage points.
Sources: CTIA, eMarketer 2010
* estimates

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Smartphone ownership in the United States is rising across all communities, with ownership among minorities outstripping that of their white peers.
Smartphone Penetration by Ethnicity
Hispanic
African American
White
Asian/Pacific Islander
45%
45%
45%
40%
42%
37%
34%
37%
33%
34%
32%
30%
31%
27%
26%
24%
25%
21%
20%
18%
Q1 2010
Q4 2009
Q2 2010
Q4 2010
Q3 2010
The widespread adoption of smartphone technology among minority communities is a significant enabler for developers and organizations that wish to address their needs.
Source: Nielsen 2011

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African Americans and Hispanics use their mobile devices for non-voice functions to a greater extent than white mobile phone owners, indicating a level of comfort with the technology.
Mobile Internet Usage by Ethnicity
Survey results clearly demonstrate that African American and Hispanic mobile users use a wide variety of non-voice applications.
The data demonstrated that minorities are comfortable using the mobile internet, making it a legitimate medium for health interventions.
Source: Pew Research Center Mobile Access 2010

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Mobile internet usage among low income communities is growing rapidly, underscoring its potential as a medium for heath interventions.
Wireless Internet Usage by Income Levels
Smartphone Penetration by Income Levels
Do not own phone
Own featurephone
Own smartphone
May-10
Apr-09
80%
3%
72%
12%
13%
23%
67%
63%
+31%
38%
55%
53%
50%
48%
46%
55%
35%
59%
39%
38%
23%
$30k-$50k
$50k-$75k
<$30k
>$75k
$30k-$50k
$50k-$75k
>$75k
<$30k
Nearly a quarter of America’s low-income adults owns a smartphone and mobile internet usage amongst this population segment is growing extremely rapidly.
Source: Pew Research Center, July 2011; Pew Research Center Mobile Access 2010

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Minorities and low-income mobile phone owners are more likely to rely solely on cell phones for internet access, compared to their white counterparts.
Wireless Internet Usage by Device
A fifth of the 60% of Americans who go online wirelessly go online exclusively via cell phone.
The probability of being a cell-only wireless internet user is higher among low SES communities.
Source: Pew Research Center

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Android is particularly popular among low SES users, making it a logical platform choice for developing mobile applications targeting this population segment.
Smartphone Platform Adoption by Ethnicity
Smartphone Platform Adoption by Income Level
26%
38%
19%
31%
31%
16%
14%
13%
12%
12%
12%
11%
11%
10%
10%
10%
9%
7%
6%
5%
4%
White
African American
Hispanic
<$30,000
$30,000 - $49,999
$50,000 - $74,999
>$75,000
Android is the dominant smartphone platform among A4G’s target population because of its affordability and wide availability on the handset portfolios of low-cost carriers.
Android is a logical platform choice for developing applications intended to address the needs of low SES communities.
Source: Pew Research Center, July 2011

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Appendix

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3. Mobile Applications as a Health Enabler
Many factors contribute to the high rates of obesity that plague low SES communities and result in diabetes, heart disease, hypertension and other conditions.
Major Consequences of Obesity
Heart Disease
Diabetes
Hypertension
Depression
Stroke
Cancers
Principal Proximate Factors Causing Obesity
Poor eating habits
Lack of adequate exercise
Principal Ultimate Factors Causing Obesity
Access to Affordable & Healthy Food
People who live in poorer neighborhoods are less likely to have easy access to fresh produce and other healthy food.
Economical &Safe Recreation
Lack of safe playgrounds accessible to poor communities and cuts to school PE budgets contribute to sedentary lifestyles.
Knowledge of Healthy Lifestyle
Lack of education about and familiarity with healthy habits and nutrition contribute to the obesity epidemic.
Genetics
Genetics have been acknowledged as a contributing factor to obesity.
Sources: American Journal of Preventive Medicine, 2009 & 2010; Economist 2011; Robert Wood Johnson Foundation; Journal of Child and Nutrition Management

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Although a fairly new area of research, early studies on the efficacy of mobile apps in affecting behavioral change have been encouraging and reveal significant potential.
Sample Organizations with Ongoing Research into Mobile Apps and Behavioral Change
Preliminary Research Results
“Medication Adherence and m-Health”, George Washington University: Researchers examined if a mobile app helped hypertensive patients in medically underserved communities stay on their medication regimens. An app named Pill Phone, developed by Vocel, was used for the study. Results showed high acceptance & prolonged use of the app. Medication use rates rose from 75% to 82% but dropped when participants stopped using it.
“Behavioral Intervention for Overweight Women”, University of California – San Diego: Researchers assessed depressive symptoms in 401 participants in a randomized control trial of a 12-month primary care, phone and internet-based behavioral intervention for overweight women. Results showed that a 1-year primary care-based phone and internet diet and exercise intervention can improve depressive symptoms.
Source: “Medication Adherence and m-Health“, George Washington University;“Behavioral Intervention for Overweight Women”, University of California – San Diego

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The widespread adoption of mobile technology presents an opportunity to develop apps that have the potential to promote and aid healthy living.
Educating
Enabling
Description:
Educational resources are needed to increase understanding of causes and solutions for obesity-related health issues
Description:
Apps can help address access inequities related to food, recreation, and healthcare
Examples:
Where is healthy, affordable food sold nearby, accepting SNAP?
Are there free clinics or Medicaid providers nearby?
Where are nearby, safe parks with hiking trails & no entrance fees?
Examples:
Nutrition: Foods to avoid and those to incorporate into a healthy diet
Exercise: How to incorporate more exercise into your daily routine
Disease-specific: tips for controlling blood pressure
Mobile Health App Types
Monitoring
Intervening
Description:
Preventing obesity and managing obesity-related chronic conditions by tracking, recording and evaluating various indicators
Description:
Actively engaging users via well-timed messages to help maintain health regimen
Examples:
Medication, insulin testing and doctor visit reminders
Use of mobile sensors and other data to determine the optimal time to send a prompt with a targeted behavioral message
Examples:
Tools to track and improve diet and exercise
Tools to monitor blood sugar and cholesterol

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4. Mobile Health Apps Overview
Health app adoption is in its infancy, but early signs point to adoption across all income levels and minority groups.
Health App Adoption by Income Level
Health App Adoption by Ethnicity
% of cell phone users
12%
11%
15%
African American
8%
7%
Hispanic
11%
7%
White
<$30k
>$75k
$50k-$75k
$30k-$50k
Current adoption of health applications by African Americans and Hispanics outstrips adoption by their white counterparts.
Although adoption by low-income communities is lower than that of higher-income groups, the deviation is not statistically significant.

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Health, fitness and medical apps constitute just 3% of all apps in the Android Market, but tend to have a higher selling price compared to the average app in the market.
Android Market by App Category
Comparison of Health & Medical Categories
Multimedia & Entertainment
17%
17%
Books & Reference
Information & Education
Games
3%
Health & Fitness
6%
11%
Medical
2%
Productivity & Tools
1%
Shopping
12%
Social
15%
1%
Travel
2%
Communication
13%
Other
Health, fitness and medical apps constitute a small proportion of the overall app market.
These apps tend to command a higher selling price than the average app.
Medical apps tend to be of higher quality than health & fitness apps, as rated by users.
Sources: Detecon Analysis, July 2011; www.appbrain.com

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Educating and monitoring apps comprise the majority of Android apps evaluated. Enabling and intervening apps are limited – both in number and in quality.
Overview of App Functionality
Android Market by App Functionality
A detailed evaluation of over 150 top-rated and downloaded Android apps in the health, fitness and medical categories indicated that 74 were relevant for obesity-related use cases (graphed on the following slide).
The chart below illustrates the functionalities of the 74 apps reviewed:
Educating
50 (68%)
Enabling
15 (20%)
48 (65%)
Monitoring
Intervening
13 (18%)
0
70
60
10
20
30
40
50
80
Most Android apps currently perform an educational or monitoring function
Relatively few enabling apps available (probably due to lack of appropriate or sufficient data) and relatively few intervening apps available (probably due to complexities of app design involving intervention time, manner etc.)
Source: Detecon Analysis, July 2011

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Apps that integrate personalization, social and gaming features are still in the minority. These features need to be better used if mobile apps are to change behavior.
Android Apps by Features
Features for Behavioral Change
Informative
Educate users about healthy behaviors and habits; provide tips for success and positive outcomes
Interactive & Personalized
Customize recommendations, workouts, recipes, etc. to user-specific health needs, circumstances and preferences with attention paid to specific socio-economic and cultural factors
Mix Social & Gaming
Use social networks and peers to motivate and encourage users; leverage games, competition, goal-setting and rewards to help users meet their goals
A detailed evaluation of over 150 top-rated and downloaded Android apps in the health, fitness and medical categories indicated that 74 were relevant for obesity-related use cases (graphed on the following slide).
The chart below illustrates the features of the 74 apps reviewed:
Informative
97% (72)
Interactive & Personalized
43% (32)
Social + Gaming
27% (20)
80
70
60
50
40
30
20
10
0
To promote behavioral change, apps should be informative, personalized and social, and include gaming features.
The most popular obesity-relevant Android apps are informational in nature. However, they are simple and lack the more sophisticated personalization, social and gaming features necessary to motivate people to adopt long-term change.

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A review of apps relevant for obesity-related health issues reveals a large number of apps targeting obesity causes but few targeting low SES communities.
Android Health App Focus Areas – Search Based Estimation
Relevant Apps
Relevant apps are defined as those that aid preventative or remediation efforts for obesity or related health issues.
Based on this criteria, Detecon evaluated the availability and functionality of apps in the Android Market that target:
Obesity Causes
Nutrition
Exercise
Lifestyle (e.g. stress)
Weight Control
Obesity Consequences
Diabetes
Heart disease
Hypertension
Low SES Communities
The chart below reflects the current distribution of Android Market apps relevant for obesity-related use cases.
The search used proxies for target use cases (e.g. calories for weight control; Medicaid & food stamps for communities with low SES).
2,484(34%)
2,090(29%)
2,081(28%)
1,187(16%)
347(5%)
354(5%)
266(4%)
18(0%)
Low SES
Hypertension
Heart Disease
Diabetes
Lifestyle
Weight Control
Exercise
Nutrition
Android Health App Focus Areas – In-Depth Estimation
A detailed evaluation of over 150 top-rated and downloaded Android apps in the health, fitness and medical categories indicated that 74 were relevant for obesity-related use cases. They are represented in the chart below.
47(64%)
28(38%)
23(31%)
9(12%)
7(9%)
6(8%)
5(7%)
4(5%)
Low SES
Hypertension
Heart Disease
Diabetes
Lifestyle
Weight Control
Exercise
Nutrition
*App might target multiple use cases

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Features
Marketing
Functionality
5. Preliminary Gap Analysis
The following areas merit attention as A4G seeks to spur app development aimed at reducing obesity rates and poor health outcomes among communities of low SES.
1
2
3
Monetization
4
What monetization strategies are currently employed?
Are there other or new strategies we might look to in the future?
How can A4G overcome the challenges of app discovery and increase awareness of relevant app resources among its target audience?
What app functionality is most needed, or missing, among currently available apps?
Educating
Enabling
Monitoring
Intervening
What types of app features will help improve health outcomes?
What types of app features are currently missing among available apps?
What considerations, specific to A4G‘s target population, must developers bear in mind?
Detecon interviewed healthcare and information design researchers, as well as app developers, to explore the questions above and gain insight into needs, trends and potential solutions.

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Apps targeting low SES communities and obesity consequences are notably missing from the market. Apps that act as enablers or intervention tools are also needed.
App Availability by Functionality
Intervening
Educating
Monitoring
Enabling
Comments
Obesity Causes
App Availability by Focus Area
Obesity Consequences
Low SES Groups
Comments
Very few apps;
Low quality
Many apps;
High quality

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Obesity Researchers
It is important to communicate that even a small (10%) reduction in weight will translate into significant health benefits.
Creating and sustaining behavioral change:
Skill-building
Self-monitoring skills are the most critical (weight, eating, exercise, mood)
Skills to set up an environment that is conducive to maintaining healthy habits
Goal-setting
Ongoing support
App usability must be designed to be inclusive of users with low literacy and numeracy.
Interventions must balance everyday realities: can users really afford to research, find and follow healthy recipes (from both a time and money perspective)? If not, what are the options?
Are users in a position to have the time and energy to devote attention to weight loss? (Maslow’s hierarchy of needs)
Researcher Focus
Catering to Low SES Audience
What are the most effective strategies for keeping patients engaged with the health regimen and preventing relapse? (It is fairly easy to get them going.)
How can we predict when a patient is going to relapse?
How do you know when to prompt a patient? When is the optimal time for a reminder (for example, to exercise) to pop up so that the patient is most receptive to the message?
Personalization: delivering relevant content (even if personalization options are bucketed into a finite number of options)
Customization: patients prefer the ability to tailor the type and frequency of contact they receive from the app
Accountability: patients enjoy receiving feedback and feeling accountable, but they want to control how/when the app interacts
Human touch: patients enjoy themselves and are more responsive if they believe there is a real person behind the communication.
Some programs sign all correspondence (even if the automated ones) with the name of the provider that the patient interacted with during the initial program set-up.
Timeliness: Technical interventions need to be a presence and resource for in-the-moment decision-making
Emerging Features for Health-Related Apps
Questions for Further Investigation

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User Interface Designer
As a diabetic, I have sat in healthcare classes and witnessed the difficulties common among fellow sufferers, particularly those with less education.
Creating and sustaining behavioral change:
Combining principles of information design with those of persuasion design to better motivate users to adopt and sustain healthy habits. Leveraging:
Fogg’s persuasion theory
Maslow’s Theory of Human Motivation and hierarchy of needs
It is important to offer users small ways to begin a program and ramp incrementally so they do not become overwhelmed and resort to excuses as to why they cannot take on such a daunting undertaking.
App usability must be designed to be inclusive of users with low literacy and numeracy.
It can be challenging to figure out what the right portion size & nutrient mix is, given the skills required to interpret & utilize label information
Use less words, more images.
One-size-fits-all dietary regimens won’t work. They need to take into account racial/ethnic backgrounds e.g. the role that rice and corn play in traditional Asian and Hispanic diets respectively.
UI Designer Focus
What are the most effective strategies for increasing frequency of use, motivation and learning?
What are the optimal ways to leverage information design and persuasion techniques to achieve behavioral change?
Instruction: include tips in games and wherever possible to educate and increase awareness
Comprehensive, searchable database: increases the value of the tool and its educational potential (nutritional info, store locations, etc)
Fun: entertaining and enjoyable apps increase stickiness
Games: are fun but also incorporate other important features:
Incentives & rewards (virtual or real): motivate people
Competitiveness/goal-setting: another significant motivator
Social: sense of community and points of comparison are important
Multiple data-entry options (type, scan labels, etc): ease of use
Consequences: use predictions of future health consequences to build awareness and motivate users to make changes now

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App Developers
You should make an effort to develop a relationship with the app stores to get your app featured – one of the best ways to drive app discovery.
Create and maintain a popular mobile app; drive
Activation
Retention
Referrals
Revenue
The absence of feedback in this area underscores how little developers are thinking about catering to needs specific to communities with low SES.
In fact, many could not think of reasons that low SES users’ needs would differ from that of other users.
App Developer Focus
How do you overcome app discovery challenges with techniques that have high ROI?
How do you migrate users from casual to high-value?
Simplicity: tasks can’t be too burdensome or people won’t stick with it
Usability: must be top notch to stand out and drive retention
Social: integration with social networks is important for driving engagement; ‘a sense of community means you’re not alone’
One developer reported that adding photo thumbnails to his app made it more personalized and drove up engagement.
Personalization: critical for relevance, engagement and stickiness
Comprehensiveness: a strong, frequently updated, backend database is needed to power high-quality tools and accurate
Fun: fulfills user wishes and contributes to stickiness
Feedback loop: app store reviews, comments on community boards, and emails provide helpful sources of user feedback for developers

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App Store Manager
There are a lot of things you can do to promote an app, but there is no substitute for app quality.
Build and maintain a profitable app store by:
Building a loyal base of end-users (by)
Promoting and distributing a variety of high-quality applications (by)
Gaining traction as a valuable partner among developers
One option would be to create a dedicated app store for apps that cater to low SES communities.
This strategy creates an additional app discovery challenge as the specialized app store then needs to be promoted to the target audience.
App Store Manager Focus
What strategies for promoting and distributing apps will prevail? Will we see app store consolidation or fragmentation?
How will the role of app stores evolve relative to marketing and curating apps?
In-app advertising should not be overly intrusive.
A paid version of a freemium app has to offer more than just the same app absent advertising. There has to be real value offered to the consumer.
Successful apps are well-designed and look nice, in addition to offering valued functionality.
While developers have historically been fairly poor marketers, the ability to promote one’s app, stand out and garner attention from users has become increasingly critical to the success of an app.
The importance of frictionless payment options (such as carrier billing) is fast increasing.

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6. Conclusions & Next Steps
Educating & Enabling: While there are a wide array of educating apps available, there is a strong need for enabling apps, particularly geared at communities of low SES. For example, apps focused on helping low SES consumers identify where to purchase affordable and healthy food with SNAP would address a need accurately felt by A4G‘s target population.
Monitoring: There is also a need for high-quality monitoring apps that are user-friendly and sticky enough to motivate users to continue using them over long periods of time to maintain healthy regimens.
Intervening: Because mobile phones are in close proximity to users at all times, there is tremendous potential for apps to be used as intervening mechanisms to promote good habits and, potentially, discourage bad ones. (For example: reminders to take medication; prompts to exercise at regular intervals, etc) New sensor technologies embedded in phones may further enable the development of apps with targeted behavioral interventions.
Low SES: A4G‘s target population faces a range of adverse circumstances, many of which could create barriers to undertaking and maintaining healthy habits. A comprehensive understanding of those circumstances will help developers better cater to the segment.
Functionality
Identify and promote existing market-leading educating apps that can help users fight obesity-related health issues.
Initiate market research to better understand the specific challenges, needs, motivators and preferences of the low SES target segment.
Partner with developers of market-leading apps to add supplemental enabling functionality targeted to low SES communities.
Partner with developers to build new apps designed to meet the needs of low SES communities that offer enabling, monitoring and intervening functionality.
Key Findings
Next Steps for A4G

Frame Template
Informative features are common in the market, but to build a loyal base of frequent users, apps will need to incorporate a wider variety of features.
Next generation apps will differentiate themselves and boost quality by integrating a host of features that will improve their value proposition, stickiness and effectiveness. For example:
Personalization to increase relevance;
Social components to increase sense of community;
Gaming to leverage users‘ competitiveness and increase fun factor, retention and motivation.
Goal-setting can be a powerful technique for behavior change. Apps that help users set realistic goals, develop plans and skills needed to reach those goals, and monitor progress along the way, are positioned to offer formidable tools for instilling healthy habits.
Robust apps that offer some of the most valuable tools for both education and behavioral change incorporate comprehensive databases which provide a rich source of information from which users can draw as they improve their own skills and decision-making.
Low literacy and numeracy of some low SES users could be addressed with features such label scanning and audio prompts
Features
Conduct or sponsor market research to better understand the specific challenges, needs, motivators and preferences of the low SES target segment.
Expert knowledge of A4G’s target market preferences, behaviors and challenges will help A4G collaborate with developers to design appropriate solutions, user experiences and applications to drive positive behavioral change.
A4G might also consider sponsoring studies to research optimal tactics to overcome the challenges of low literacy and numeracy.
Usability and features designed with these users in mind will expand mobile app access to a broader population.
Key Findings
Next Steps for A4G

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Lower income and less educated users are less likely to have a health app installed on their mobile phone, despite poorer health outcomes, suggesting there is a significant opportunity to improve awareness among A4G‘s target population.
App discovery is a significant challenge across the mobile ecosystem and even more acute for applications targeting a smaller, often-marginalized group of users.
Increasingly, app developers are testing a variety of marketing avenues for efficacy and ROI, including:
Mobile advertising (usually a pay-per-download model)
Offline advertising
PR for apps (which includes everything from building a more attractive app store icon to wrangling press coverage for the app)
SEO (search engine optimization) for mobile app stores
Cultivating relationships with app store owners to land a “featured” spot in the app store
Marketing
A4G is well-positioned to leverage its association with One Economy and the Beehive to establish partnerships that facilitate reaching its target audience. For example:
The Beehive has a health section which is targeted to users of low SES. Market-leading and low SES-targeted apps could be promoted effectively via this outlet.
One Economy‘s partners in bringing broadband to underserved communities (particularly in public housing projects) could also be tapped to help promote awareness of leading health apps.
Additionally, A4G could create a ‘Featured Apps‘ page on its website and promote the page among target groups to boost awareness. This central clearinghouse could serve as a destination for A4G‘s target audience looking for a curated list of apps well-suited to their needs.
A4G could develop a list of marketing guidelines or best practices for developers seeking to serve A4G‘s constituents.
A4G could also develop partnerships with corporate entities (such as insurance, pharmaceutical and food companies) to develop co-marketing campaigns.
Key Findings
Next Steps for A4G

Frame Template
Currently, apps are commonly monetized via
In-app advertising
In-app purchases
Freemium model (wherein a free basic version of the app serves as a teaser for an enhanced-functionality version)
Monetization
A4G could explore creative, new monetization and pricing models. For example, collaborating with corporate partners (such as pharmaceutical and insurance companies) to develop and pilot new monetization strategies.
Health insurance companies might benefit from subsidizing app development and distribution costs if apps can help reduce other costs such as hospitalizations resulting from drug non-compliance or poor health conditions as a result of unhealthy (nutrition or exercise) choices.
Example: State Farm sponsored an app called On the Move that sends automatic text message replies while the user is driving. The company hopes the app will help users avoid distracted driving, thereby saving the company money by reducing the number of accident claims.
Key Findings
Next Steps for A4G

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Appendix

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Market Need Assessment & Gap Analysis: Profile of a Popular mHealth App
‘Fooducate’ is a popular app promoting healthy eating. Enhancements such as healthy recipe suggestions and information on local grocery stores accepting food stamps could appeal to A4G’s target audience.
Example
App Details
Fooducate Snapshot
Potential Enhancements for A4G’s Target Population
Fooducate’s Description on Android Market
Use an Android phone to:
automatically scan a product barcode
see product highlights (both good and bad)
select better alternatives
Fooducate analyzes information found in each product's nutrition panel and ingredient list
You get to see the stuff manufacturers don't want you to notice
Recipe suggestions personalized for health conditions
Links and directions to grocery outlets that carry suggested products and accept food stamps
Matching suggested products with store discounts or coupons
Social features for sharing recipe information, nutritional information and sales with friends

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Market Need Assessment & Gap Analysis: Profile of a Popular mHealth App
‘OnTrack’ is a popular app for diabetics to monitor their condition. Potential add-ons for low-income users include providing relevant nutrition and medication info.
Example
Details
OnTrack Diabetes Snapshot
Potential Enhancements for A4G’s Target Population
OnTrack Diabetes’ Description on Market
Manage diabetes better by tracking blood glucose, medication and other values.
OnTrack helps diabetics manage their diabetes by tracking various items such as blood glucose, food, medication, blood pressure (BP), pulse, exercise and weight.
Features include:
Add multiple entries simultaneously, for example add glucose and medication at one time quickly and easily & a variety of detailed graphs and reports
a detailed log book with tables and graphs suitable for sharing with your doctor
activate reminders (e.g. remind yourself to test two hours after eating food)
Community forums for diabetics to share tips, support and information
Information for low-income diabetics to get medication and treatment ideas
Connections to recipe sites that provide suggestions suitable for low-income diabetics

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Interviews
Interview Contacts
Aaron MarcusPresident and Principal Designer/Analyst, Aaron Marcus and Associates, Inc. (AM+A)
Sergey OreshkoCEO, 4Technologies Corporation (MyNetDiary)
Mike PrinceCo-founder, AlltheCooks
J. Graham Thomas, PhD Assistant Professor (Research), Weight Control & Diabetes Research Center, The Miriam Hospital & Brown Medical School
Hemi WeingartenCo-Founder & CEO, Fooducate
Rena Wing, PhDDirector, Weight Control & Diabetes Research Center at the Miriam Hospital, RIProfessor, Department of Psychiatry and Human Behavior, Brown University Medical School
Brian Hickey
Developer Relations, GetJar

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Mobile health apps for low income communities

by App Master

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