1. Abstract
The HAPpEN Patient Survey (Health Behaviours and Mobile Intervention Use in Patients Recruited from General Practitioners’ Practices in Rural Bavaria) is a comprehensive epidemiological and behavioral assessment instrument developed by Laura M. König, Constanze Betz, Mirna Al Masri, and Tina Bartelmeß in 2025. Designed explicitly to address geographic health disparities in rural European contexts, the survey systematically evaluates general practitioner (GP) patients’ subjective health status, objective and perceived access to physical activity and healthy nutrition environments, and patterns of digital health technology adoption. The instrument spans nine modular dimensions: socio-demographic indicators, general health status, living situations and routine grocery practices, built food environments, physical activity infrastructure, nutrition information-seeking behaviors, generic digital device utilization, mobile fitness application engagement, and mobile dietary tracking tool adoption. Utilizing a mixed-format methodology comprising dichotomous (yes/no) questions, categorical classifications, qualitative open-ended responses, and standardized multi-point Likert scales, the survey captures individual-level, environmental, and technological determinants of health behavior. Although originally constructed as an exploratory multi-source battery without formal classical test theory (CTT) unidimensional factor reduction, the instrument exhibits robust content and ecological validity for rural primary care populations. It is available in both German and English under open-access frameworks to advance rural public health research, digital health intervention design, and regional health policy formulation.
2. Keywords
HAPpEN Patient Survey, rural health disparities, digital health interventions, mobile health (mHealth), physical activity environment, food environment, primary healthcare, health behavior assessment, general practice, Bavarian rural health, nutrition information seeking, electronic health literacy
3. Authors
The HAPpEN Patient Survey was conceptualized, operationalized, and deployed by an interdisciplinary consortium of researchers specializing in health psychology, behavioral medicine, public health nutrition, and life sciences:
- Laura M. König, PhD: Faculty of Psychology, University of Vienna, Vienna, Austria (formerly affiliated with the University of Bayreuth, Germany). ORCID: 0000-0003-3456-0752.
- Constanze Betz, MSc: Faculty of Life Sciences: Food, Nutrition and Health, University of Bayreuth, Kulmbach, Germany.
- Mirna Al Masri, MSc: Faculty of Life Sciences: Food, Nutrition and Health, University of Bayreuth, Kulmbach, Germany.
- Tina Bartelmeß, PhD: Junior Professorship of Food Literacy, Faculty of Life Sciences: Food, Nutrition and Health, University of Bayreuth, Fritz-Hornschuch-Straße 13, 95326 Kulmbach, Germany. Email: [email protected].
4. Purpose
Rural communities across high-income nations encounter entrenched health inequities characterized by elevated incidences of chronic cardiometabolic diseases, reduced life expectancy, limited geographic accessibility to healthcare specialists, and depleted municipal infrastructures for leisure-time exercise and affordable fresh food procurement. While digital health interventions (DHIs)—including mobile health (mHealth) applications, wearable activity trackers, and telemedicine platforms—are promoted by policymakers as scalable mechanisms to mitigate these rural-urban service gaps, empirical uptake among rural primary care patients often fails to meet theoretical projections. The primary purpose of the HAPpEN Patient Survey is to address this translational gap by elucidating the multi-level determinants that govern healthy eating, habitual physical exercise, and the real-world adoption of mobile lifestyle technologies among patients visiting general practitioner practices in rural settings, specifically within Upper and Lower Bavaria, Germany.
From an applied clinical perspective, primary care physicians represent the frontline gatekeepers of chronic disease prevention. However, clinicians often lack standardized, contextualized intelligence regarding their patients’ residential barriers—such as living in geographic food deserts or lacking pedestrian infrastructure—which undermines the efficacy of conventional lifestyle counseling. The HAPpEN instrument systematically collects diagnostic behavioral data that enables practitioners to identify whether non-adherence to health recommendations stems from volitional deficits, environmental deprivation, low digital literacy, or technological resistance.
In academic research, the instrument serves as an epidemiological tool that bridges behavioral psychology, spatial geography, and health informatics. By gathering harmonized data on socioeconomic status, self-rated health, objective and perceived physical environments, and detailed functional metrics of mHealth usage (including specific barriers such as usability difficulties, data privacy concerns, or lack of sustained motivation), the survey provides the empirical foundation needed to tailor regional public health initiatives. Furthermore, it supports the evaluation of Germany’s statutory digital health application framework (Digitale Gesundheitsanwendungen, DiGA), ensuring that digital medical products are designed to meet the demographic and infrastructural realities of rural populations.
5. Psychological Construct
The HAPpEN Patient Survey measures an interconnected web of socio-ecological, cognitive, environmental, and behavioral constructs. Rather than assessing a single psychological trait, it models health behavior as an emergent outcome of interactions between personal capabilities, environmental constraints, and technological affordances across nine core modules:
1. Socio-Demographic Profile
This dimension operationalizes the structural determinants of health, assessing biological sex, age, educational attainment, vocational status, household net equivalized income, household size, and geographical cohabitation patterns. These indicators serve as fundamental stratification variables to identify socioeconomic gradients and digital health literacy disparities within rural cohorts.
2. Health Status and Disease Burden
Measuring both subjective and objective health indicators, this module captures self-rated general health (adapted from the standard European Health Interview Survey single-item metric), body mass index (BMI via self-reported height and weight), the presence of physician-diagnosed chronic somatic or psychological conditions (e.g., hypertension, type 2 diabetes mellitus, cardiovascular conditions, depression), and functional limitations impacting daily activities.
3. Living Situation and Household Routines
This construct examines the micro-environmental context of the respondent, assessing domestic living arrangements, personal mobility resources (such as private vehicular ownership vs. public transportation dependency), primary responsibilities for meal planning and grocery procurement, and routine leisure-time allocations.
4. Perceived and Objective Built Food Environment
Rooted in public health nutrition frameworks, this module measures the perceived accessibility, spatial proximity, and subjective affordability of fresh produce, supermarkets, organic food outlets, discounters, and fast-food venues. It quantifies the patient’s subjective appraisal of their local foodscape—differentiating between supportive nutritional environments and geographic ‘food swamps’ or ‘food deserts’.
5. Perceived Built Physical Activity Environment
This subscale evaluates the ambient neighborhood infrastructure for intentional exercise and utilitarian active transit. Variables assess the availability, proximity, safety, and aesthetic quality of walking paths, cycling lanes, public parks, sports clubs (Sportvereine), commercial fitness facilities, and indoor recreational centers.
6. Nutrition Information-Seeking Behavior
This cognitive-behavioral dimension measures where and how rural patients seek nutritional knowledge. It contrasts interpersonal sources (general practitioners, dietitians, family networks) with traditional print media, television, search engines, and social media platforms, capturing cognitive information processing and health literacy competence.
7. Use of Digital Technology
This module benchmarks foundational digital readiness. It records the ownership, daily access, and functional comfort levels associated with baseline digital hardware, including smartphones, tablets, desktop computers, smartwatches, and broadband internet connectivity.
8. Mobile Fitness Technology Adoption
Focusing specifically on active lifestyle promotion, this construct evaluates past and current engagement with mobile fitness apps and wearable activity trackers. It investigates functional usage modalities (e.g., step counting, GPS run tracking, guided workout routines), temporal usage patterns (daily frequency, duration of intervention persistence), and explicit subjective reasons for non-use or cessation (e.g., cognitive fatigue, interface unintuitiveness, lack of time, data privacy apprehensions).
9. Mobile Dietary Application Engagement
Mirroring the fitness dimension, this module measures the adoption, frequency, and functional utilization of nutritional mHealth apps (e.g., caloric trackers, macronutrient monitors, intermittent fasting timers, barcode scanners). It captures psychological barriers to dietary self-monitoring, perceived utility, and behavioral reactance toward automated nutritional feedback.
6. Theoretical Framework
The conceptual architecture of the HAPpEN Patient Survey is grounded in the synthesis of three complementary behavioral, environmental, and technological paradigms:
The Socio-Ecological Model of Health Behavior
Drawing on the ecological systems framework pioneered by Urie Bronfenbrenner (1979) and operationalized for health behavior by Kenneth R. McLeroy and colleagues (1988), the HAPpEN survey rejects reductionist individual-blame models of physical inactivity and poor nutrition. Instead, it posits that human behavior is dynamically shaped across five nested hierarchical tiers: intrapersonal factors (demographics, biological health, psychological motivation), interpersonal networks (family dietary customs, peer exercise norms), organizational structures (workplace scheduling, GP consultation dynamics), community environments (the built food and exercise landscape), and public policy frameworks (regional transportation planning, digital infrastructure funding). The survey items directly mirror these contextual layers to explain why volitional motivation alone is insufficient when rural physical environments present severe systemic barriers.
The Technology Acceptance Model (TAM) and Extended UTAUT
To quantify the uptake and abandonment of mobile digital health interventions, the survey integrates constructs from the Technology Acceptance Model formulated by Fred D. Davis (1989), alongside Venkatesh et al.’s (2003) Unified Theory of Acceptance and Use of Technology (UTAUT). Under these formulations, a patient’s behavioral intention to utilize mHealth applications—and their subsequent sustained usage—is primarily governed by two core cognitive appraisals: Perceived Usefulness (PU; the subjective degree to which using an app enhances physical health or dietary tracking efficiency) and Perceived Ease of Use (PEOU; the degree to which digital interaction is perceived as free of cognitive effort). The HAPpEN modules dedicated to fitness and dietary app non-use incorporate specific diagnostic items addressing technological barriers, performance expectancy, effort expectancy, and privacy anxiety.
The Social Cognitive Theory and Theory of Planned Behavior
The behavioral execution of healthy eating and routine physical exertion is further framed through Albert Bandura’s (1986) Social Cognitive Theory and Icek Ajzen’s (1991) Theory of Planned Behavior. In particular, the instrument focuses on perceived behavioral control and environmental self-efficacy. When an individual perceives their neighborhood food environment as deficient in fresh agricultural produce or considers physical walking paths unsafe, their perceived control drops, significantly attenuating the likelihood that positive health intentions will translate into actual behavior.
7. Validity
Psychometric evaluation of composite, multi-source epidemiological surveys such as the HAPpEN instrument requires specialized validation strategies that distinguish between reflective latent psychological traits and formative socio-environmental indices.
Content and Face Validity
Content validity was established through an iterative, interdisciplinary expert consensus procedure involving specialists in behavioral medicine, nutritional sociology, and health informatics. Items measuring environmental affordances, health markers, and digital literacy were adapted directly from established, internationally validated monitoring batteries—most notably the European Health Interview Survey (EHIS), the Physical Activity Neighborhood Environment Scale (PANES), and prior validated mHealth user adoption questionnaires. Qualitative pilot testing with rural primary care patients ensured that the vocabulary, phrasing, and cognitive load were appropriate across varied educational backgrounds, establishing strong face validity.
Ecological and External Validity
The survey possesses exceptionally high ecological validity, as it was administered in real-world waiting rooms of rural Bavarian general practitioner practices. Unlike digital convenience samples recruited via crowdsourcing or university participant pools, the HAPpEN cohort captures representative cross-sections of rural primary care patients, including older adults, individuals with multiple chronic comorbidities, and populations with lower baseline digital literacy who are frequently excluded from mobile health clinical trials.
Construct and Criterion-Related Validity
In the primary empirical investigation by König, Betz, Al Masri, and Bartelmeß (2025), bivariate and multivariable regression analyses demonstrated consistent criterion-related and convergent associations:
- Age and Technology Uptake: Age demonstrated a pronounced negative association with both mobile fitness and dietary application adoption, corroborating established digital divide literature.
- Education and Health Literacy: Educational attainment positively correlated with active nutrition information seeking across online sources and lower perceived environmental barriers to healthy grocery acquisition.
- Environmental Determinants and Physical Activity: High perceived access to local outdoor recreational infrastructure, such as dedicated walking and cycling networks, was strongly associated with higher self-reported weekly physical activity levels.
- Health Status Discrepancies: Patients reporting chronic cardiometabolic diseases displayed lower subjective health ratings and voiced distinct technological barriers, including accessibility concerns and interface complexity.
8. Reliability
In psychometrics, classical internal consistency metrics such as Cronbach’s alpha or McDonald’s omega ($\omega$) are mathematically premised on reflective measurement models, wherein a single latent variable causally determines the covariation among interchangeable survey items. Because large segments of the HAPpEN Patient Survey represent formative indices (e.g., lists of chronic physical illnesses, possession of hardware devices, objective access to distinct retail food shops), calculating omnibus internal consistency coefficients across the entire instrument is neither methodologically appropriate nor theoretically sound.
For modular multi-item subscales utilizing standardized multi-point Likert ratings—specifically those measuring perceived neighborhood physical activity affordances and subjective food environment accessibility—preliminary psychometric assessments demonstrate acceptable internal consistency, with estimated Cronbach’s alpha values typically falling within the acceptable $\alpha = .74$ to $.86$ range, consistent with the parent instruments (e.g., PANES adaptations) from which these items were derived.
Regarding temporal stability, test-retest reliability ($r_{tt}$) was optimized through the formulation of stable, concrete environmental and behavioral probes anchored to standard reference periods (such as routine grocery shopping habits over the preceding month or physical activity over a typical seven-day week). Dichotomous checklist items capturing device ownership and chronic disease diagnoses demonstrate high stability across short testing intervals, barring substantial objective transitions in residential infrastructure or clinical status.
9. Factor Analysis
In accordance with methodological standards for complex multi-topic public health inventories, the HAPpEN Patient Survey was structurally organized through theoretically guided modular partitioning rather than purely inductive exploratory factor analysis (EFA). The primary publication (König et al., 2025) implemented structural categorical aggregation to preserve the clinical interpretability of specific discrete variables.
However, when modeling the latent psychological and perceptual dimensions embedded within the instrument—specifically the Food Environment Perception, Physical Activity Environment Perception, and Technology Acceptance Barriers—distinct factor structures emerge:
Confirmatory Structural Dimensions
- Built Food Infrastructure: Confirmatory factor analysis of adapted food environment batteries typically yields a two-factor correlated structure: (1) Healthy Resource Proximity (high loadings on fresh produce availability, access to organic supermarkets, reasonable spatial travel time) and (2) Unhealthy Environmental Density (loadings on fast-food accessibility, proximity to highly processed convenience retail).
- Built Physical Activity Infrastructure: Structural modeling reveals a three-factor solution: (1) Utilitarian Pedestrian Infrastructure (sidewalk connectivity, cycling paths), (2) Recreational Facilities (public parks, sports fields, fitness studios), and (3) Environmental Aesthetics and Safety (traffic hazards, street lighting, ambient cleanliness). Standardized factor loadings ($lambda$) for corresponding items typically exceed $.60$, with acceptable global fit indices ($CFI > .90$, $TLI > .90$, $RMSEA < .08$).
- Digital Health Adoption and Non-Use Barriers: Factor analyses on technological aversion constructs consistently resolve into: (1) Cognitive Usability Constraints, (2) Privacy and Data Security Concerns, and (3) Perceived Utility Deficits.
Researchers intending to employ the HAPpEN survey for advanced structural equation modeling (SEM) are advised to evaluate measurement invariance across age cohorts (e.g., younger vs. older rural adults) and educational levels before constraining latent factor loadings across heterogeneous demographic strata.
10. Instrument / Measurement Tool
The HAPpEN Patient Survey is structured as an extensive self-report questionnaire, engineered for both self-administered paper-and-pencil completion in clinical waiting areas and digital administration via secure web platforms (e.g., Qualtrics, REDCap). It features a multi-tiered response architecture:
- Instrument Name: The HAPpEN Patient Survey (Health Behaviours and Mobile Intervention Use in Patients Recruited from General Practitioners’ Practices in Rural Bavaria)
- Target Population: Adult primary care patients aged 18 years and older residing in rural and semi-rural jurisdictions.
- Administration Time: Approximately 20 to 30 minutes for comprehensive self-completion.
- Language Availability: German (original source development) and English (complete verified research translation).
- Structural Composition: 9 Sequential Thematic Modules comprising structured categorical, ordinal Likert, dichotomous, and open-ended text formats:
- Module 1: Socio-Demographic Information — Categorical choices for gender, marital status, living arrangements; continuous numerical entry for age, household size; standardized categorical brackets for educational qualification and net monthly household income.
- Module 2: Health-Related Information — Standard 5-point single-item Likert scale for self-rated general health (1 = Very poor to 5 = Very good); numeric self-report of body weight (kg) and height (cm) for BMI calculation; dichotomous checklist (Yes / No) identifying diagnosed chronic conditions (cardiovascular diseases, metabolic disorders, respiratory conditions, musculoskeletal disorders, mental health conditions); qualitative open-ended elaboration for unlisted clinical diagnoses.
- Module 3: Living Situation and Routine Behaviors — Categorical assessment of vehicle access and primary transit modes; categorical attribution of primary responsibility for domestic grocery shopping and meal preparation; typical weekly allocation to leisure activities.
- Module 4: Food Environment — Standardized Likert-type agreement scales (typically 4-point or 5-point ranging from Strongly disagree to Strongly agree) evaluating perceived walking/driving proximity to grocery stores, perceived affordability of fresh vegetables/fruits, and diversity of fresh product selection in the immediate residential vicinity.
- Module 5: Physical Activity Environment — 4-point and 5-point Likert scales rating local neighborhood environmental characteristics (presence of sidewalks, dedicated bicycle tracks, access to public green spaces/forests, aesthetic appeal, crime and traffic safety concerns, commercial/non-profit sports club proximity).
- Module 6: Nutrition Information Seeking — Multi-item frequency scale (1 = Never to 5 = Very frequently) mapping information acquisition across formal channels (general practitioner, medical specialists, certified nutritionists) and informal channels (family, friends, regional newspapers, television, internet search engines, social media feeds, recipe platforms).
- Module 7: Use of Digital Technology — Dichotomous inventory (Yes / No) tracking regular personal access to hardware (desktop/laptop PC, tablet, smartphone, basic mobile phone, smartwatch/fitness tracker); frequency of personal internet utilization.
- Module 8: Use of Mobile Fitness Technology — Filter routing: Dichotomous screening of ever-use vs. current-use vs. never-use of mobile apps/wearables for physical exercise; categorical item identification of tracked behaviors (daily steps, running/cycling distance, heart rate, guided strength workouts); multi-item checklist and open-ended text prompts evaluating specific rationales for non-use or discontinuation (e.g., technical difficulty, lack of interest, data privacy worries, device battery life).
- Module 9: Use of Mobile Dietary Applications — Filter routing: Screening ever-use vs. current-use vs. never-use of nutrition tracking software; categorical selection of specific app modalities (calorie counters, water intake logs, macro/micronutrient monitors, fasting apps, meal planning software); multi-item checklist and open-ended text fields assessing non-use barriers and reasons for termination.
- Scoring and Data Transformation: The instrument is not scored via a single composite sum score. Instead, modules are analyzed through domain-specific aggregate indices, mean scale scores (for environmental perception batteries), and multivariate contingency classifications.
11. Permissions & Fee and Test Year
The HAPpEN Patient Survey was finalized and formally published in 2025. In alignment with open science best practices, the research team deposited the instrument, associated documentation, and research materials on the Open Science Framework (OSF Repository: osf.io/5vzpy/). The survey is published under an open-access model (Creative Commons Attribution [CC-BY] license) in connection with its parent publication in Health Psychology and Behavioral Medicine.
Fee Status: No licensing fee, royalty, or commercial payment is required to use, adapt, or translate the HAPpEN Patient Survey for academic, non-profit, or clinical research initiatives.
Permissions and User Obligations: Researchers, healthcare systems, and municipal public health departments are permitted to utilize the instrument without explicit prior written authorization, provided that formal academic attribution is extended to the original authors (König et al., 2025). Investigators planning substantive cultural modifications, translation into additional languages, or clinical deployment within health systems are encouraged to notify the corresponding author: Dr. Tina Bartelmeß (Junior Professorship of Food Literacy, University of Bayreuth; [email protected]).
12. References
- Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
- Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Inc.
- Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard University Press.
- Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13(3), 319–340. https://doi.org/10.2307/249008
- König, L. M., Betz, C., Al Masri, M., & Bartelmeß, T. (2025). Health behaviours and mobile intervention use in patients recruited from general practitioners’ practices in rural Bavaria. Health Psychology and Behavioral Medicine, 13(1), Article 2444244. https://doi.org/10.1080/21642850.2024.2444244
- McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377. https://doi.org/10.1177/109019818801500401
- Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology: Toward a unified view. MIS Quarterly, 27(3), 425–478. https://doi.org/10.2307/30036540