Healthy Living with Persuasive Technologies: Framework, Issues, and Challenges

Introduction

Of the more than 1.7 trillion dollars spent nationally every year in health care, less than 4% is spent on prevention and public health. The growing rate of chronic diseases such as diabetes, hypertension, trauma, back problems, heart disease, and cardiovascular disease accounts for more than half of the overall growth of health care costs. Prevention services such as screening and disease management that address populations at-risk, along with primary prevention with an emphasis on improving the environments where people live, work, play, and go to school, are receiving increasing attention and helping to reduce the costs on the health care system.2

This paper reviews persuasive technologies, an area of research that has the potential to assist in health related prevention services. Persuasive computing technology is a computing system, device, or application intentionally designed to change a person's attitude or behavior in a predetermined way.3 In the decade since 1998, several emerging devices, applications, and experimental projects have appeared in the market. The point here, however, is not to list them; instead, we want to offer a deeper insight into the evolution of these technologies and ideas. We present a framework that can guide both novice and experienced researchers to comprehend more effectively the work that is being conducted in this field, provide categories of domains within health care in which these technologies are being used, and show exemplars of persuasive research projects that are successful. Our goal is to provide insights by addressing the challenges that lie ahead for all key stakeholders that design and/or use persuasive technologies in health care.

A Framework

B. J. Fogg3 defines persuasive technology as any interactive computing system designed to change people's attitudes and/or behaviors. The emergence of the Internet has led to a proliferation of web sites designed to persuade or motivate people to change their attitudes and behavior. Amazon.com doesn't just process orders, it attempts to persuade people to purchase more products. It does so by offering suggestions based on user preferences during previous visits, analysis of click-stream patterns, and feedback from other buyers. Similarly, the auction site eBay^® has developed an online exchange system with enough credibility that users are persuaded to make financial transactions and divulge personal information. Beyond the web, we see persuasive technologies expanding to other fields including environment, business marketing, education, and of course health care.

Figure 1 shows a simple framework that exemplifies how persuasive technologies can impact health care. The three circles represent: (1) technology that is the driver for persuasive change and has to be selected or designed carefully to impact health care; (2) persuasion strategies that must be employed with an intent to change behavior, attitudes, or motivation; and (3) the subdomains within health care where we see potential applications bounded by disease, lifestyle, or the natural cycle from birth to death. The size of the intersecting field within the three domains is not well understood, but given evidence of its growth from both academic literature and the media, it is expected to continue to grow quickly.

In his seminal work,3 B.J. Fogg addresses the functional triad that forms a framework for thinking about the roles played by computing products from the perspective of the user. According to Fogg, interactive computing technologies can play three roles: as tools, as media, and as social actors. As a tool, interactive computing technologies can be persuasive by making target behavior easier, leading people through a process, or performing calculations/measurements that motivate. As a medium, interactive computing technologies can be persuasive by allowing people to explore cause-and-effect relationships, providing people with experiences that motivate, or helping people to rehearse a behavior. As a social actor, interactive computing technologies can be persuasive by rewarding people with positive feedback, modeling a target behavior or attitude, and providing a social network of support. Within the health care field, we anticipate that interactive technologies will be deployed to take on more than one role at a time. For example, a simple tool can measure calories while also giving a reward upon attainment of a personal goal. If several people are connected to a server through the Internet, then social support can be leveraged, which has been shown to impact motivation and behavior change.

Persuasion, Modes, and Strategies

While philosophers and scholars have been examining persuasion for years, there is no single universal agreement on what the term really means. For this paper, persuasion is a deliberate attempt to change attitudes and/or behaviors. Note, however, that deliberate for this paper means intended and not accidental. Also, it does not connote coercion or deception. Coercion implies force; while it may change behavior, it is not the same as persuasion—which implies voluntary change.3

In order to design effective persuasive-based computing technology (PBCT), it is important to understand the different strategies that a researcher can employ when setting the role of a PBCT as a tool, a media, or a social actor. In Table 1, we list some persuasion strategies that may be used by a researcher or a practitioner.

In Fig. 2, we present a roadmap to show how persuasive-based computing technologies have evolved over the years. At the top level, we divide the available technologies into four generations. First generation (G1) systems that we call prescriptive systems started in the late 1960s and 70s and fundamentally dealt with human one-on-one persuasion with a physician or health care provider trying to convince a patient to take care of their health. In terms of technology, telephones were widely used and a computer-generated brochure (or CD-ROM) containing additional information about a disease or health condition was often given to a patient.

Second generation (G2) systems are what we call descriptive systems. With the popularity of the Internet, we see web-based systems being designed to provide information and educational content (such as http://www.webmd.com) delivered to users first through PC's and later through cell-phones. The content shared was more than text; multimedia data such as images, audio, and video became commonly used.

Third generation (G3) systems that we call environmental systems dominate the marketplace in 2008. Three characteristics distinguish these systems from their predecessors: (1) use of body-wearable sensors that collect, store, and share relevant data; (2) use of context-aware technologies that attempt to infer a subject's present state and use that information to impact change; and (3) real-time exchange of information giving rise to such concepts as “just-in-time” motivational messages delivered over a wide variety of devices.4 The trend is toward the use of mobile devices such as cell-phones and PDA's.

Lastly, innovations that follow G3 systems represent the future systems of persuasive technologies. They are characterized by advanced automation techniques in which human intervention is minimal. These systems rely on extensive pervasive sensing of the users environment and they provide the ability of powerful software engines that can process, mine, and send suggestions in a completely automated way. Such technologies will leverage the advances in pervasive computing, sensor technology, and agent technology.5 6

In order to understand how these generational systems have evolved and how new systems can be designed, built, and deployed, we show in the roadmap three additional layers on which these technologies rest. The first layer is called “Human Elements” and must address human aspects that include profile/demographics, behavior/motivation/attitude, and social elements to have an impact by PBCTs. Understanding human behavior change theories is critical.7 We increasingly see an affinity for social networks and predict that the next generation systems will capitalize on the social networking phenomenon and will provide incentives for baby boomers to adopt PBCTs as they age with technology.

The second layer is called “Technology Foundations.” This layer is an enabler and delivers the technology to the end-user. The three important components of this layer include:

• Devices/hardware—we envision several different kinds of devices and hardware platforms to be used in designing such systems. They will include PC's, laptops, mobile phones, PDA's, Apple iPods,^® specialized tablet computers, game consoles such as the Nintendo Wii, and various sensors like the ones shown in Table 2.

• Software/applications—we envision a range of applications that will be designed to leverage the variety of hardware for which these systems are developed. There are critical challenges in software design which we will address later.

• Networks/Internet—we envision new network technologies that will function as the glue to make ubiquitous PBCTs a reality. The TCP/IP protocol will become the de facto protocol to be used in such systems. The use of the mobile Internet will continue to grow, bandwidth will be a valuable commodity, and latency issues will continue to impact performance.

The third and last layer is termed “Interaction Capabilities.” The three generation systems differ in their data types. G1 systems are predominantly text-based while later generation systems are multimedia, using audio, video, images, and high resolution multimedia data types. They also differ in their periodicity of sending and updating messages. Earlier systems had very low periodicity of exchange. Typical interactions might be daily, weekly, or monthly. Later generation systems have a higher periodicity of data exchange that might be seconds, minutes, or less than an hour. In real-time G3 systems, data are continuously sent to a context-aware server and relevant feedback is sent back immediately.8 Real-time data collection in itself is a big research challenge.

The generational systems also differ in their temporal nature of interaction, with time being measured in discrete units or in real time. Customization also differentiates these systems. In early generation systems, information was more generic and not suited to the context or situation in which the subject was placed. Newer systems have a high level of customization so the right message and content can be delivered at the right time and place. Web-based systems now provide customization capabilities and can learn and adapt to the user's changing requirements.

Survey of Exemplars of Persuasive Technologies from Published Literature

The use of technologies to persuade and motivate behavior change has been an active domain for research. Table 3 provides a list of exemplary research that fits each generation as outlined in this paper. While not inclusive of all work done in the use of technologies to support healthy living, it does provide the reader with a survey of current research activity.

The research literature highlights the evolution of technologies used to impact health care and the changes in information flow between patient and health care provider. G1 systems are characterized by the prescriptive nature of information flow from physician, health care provider, or technology-based system to a health care recipient with most research outcomes over the years yielding the conclusion that phone-based or simple messaging technologies can improve the quality of health care management and clinical outcomes.

G2 systems are characterized by the descriptive nature of information interaction between a user and the persuasive technologies. These include interactive Web sites, personal data assistants (PDAs) that allow activity recording, and simple sensors that record and report basic health parameters. G2 systems allow for richer information dissemination over G1 systems with multimedia content that can be audio or visual, and text messages that combine to build systems that allow the user to become immersed in the operating space.

G2 technologies move beyond G1 technologies that are often limited to simple messaging and one-size-fits-all approaches and support persuasive interventions that are tailored or adapted for various and changing states of behavior change readiness among the targeted recipients. This design paradigm of “deliver the right message at the right time” requires “multiple forms of communication delivery and variation in the content of messages delivered”21 and is made possible with computers, advances in sensor technologies, and the global reach of the Internet.

The use of G2 systems to change behavior is well documented in research settings. Sensor technologies vis-à-vis wrist-worn accelerometers to monitor physical activity, mobile phones that allow users to record workouts and determine caloric expenditures, and other monitoring devices like the BodyMedia's BodyBugg22 that resides on a users arm and uses physiological sensors and data modeling to measure health routines are leveraged in the studies to support the change.

While most of the research studies cite custom technological applications and designs, commercial products do exist that provide personal awareness of activity level or determination of health state. The Kogan GPS watch allows an owner to monitor heart rate.23 Omron manufactures pedometers that allow a user to track step-counts and several models support activity tracking and analysis via health management software.24 For the runner, the Nike+ iPod^® uses an accelerometer embedded in a shoe and communicates with an Apple iPod^® to report workout states (e.g., the distance and pace of a walk or run) and also provides positive feedback for goal-oriented workouts with pre-recorded congratulation messages provided by Lance Armstrong, Tiger Woods, and Paula Radcliffe at the achievement of a workout milestone.25 Each of these commercial products further exemplifies G2 technologies that drive persuasion ideology to impact various health care subdomains.

G3 systems extend G2 capabilities by the inclusion of body-wearable sensors that support advanced health monitoring, use of context-aware computing that can use information of a person's location within their environment and the determination of their activity at the moment of measurement, and real-time exchange of information to support “just in time” messaging.

Supporting technologies in G3 systems leverage the recent advances in microchip fabrication and wireless networking, and the integration of embedded microcontrollers, physical sensors, and radio interfaces on a single battery-powered chip allows for new medical applications not available in past generations. These miniature, wireless, and wearable sensor nodes can be placed on a patient to allow for the untethered measurement and monitoring of various health factors including high blood pressure, irregular heartbeats, or physical conditions tied to diabetes or obesity. Non-evasive and invasive sensors are used to monitor these medical parameters and report alerts to the user and/or health care provider. Various real-time patient monitoring projects have been developed, including UbiMon (Ubiquitous Monitoring Environment for Wearable and Implantable Sensors), whose goal is to provide continuous and unobtrusive patient monitoring for the capture of life threatening events, and CodeBlue,^® a wireless sensor network model that supports a range of medical applications including hospital monitoring, stroke patient rehabilitation, and Disaster response.26

According to Mukhopadhyay et al.,27 “Sensor networks permit data gathering and computation to be deeply embedded into the environment.” These technologies can manifest context-aware systems that deduce a person's activity from their environmental state. Context-aware systems are exemplified in work done by Hassan and Chatterjee8 28 and are being used in assisted-living complexes in monitoring the health states of their occupants. With the rise in the number of baby boomers (it is predicted that those aged 65–85+ will make up more than 18% of the population of the United States by the year 202529), research is being conducted on in-residence elderly monitoring that can provide several benefits, including providing peace of mind for adult children who can remotely monitor their loved ones, collecting real-time logs of physical activities and health parameters for examination by health professionals located at distant sites, and the detection of anomalous patterns in behavior or physical conditions that may forewarn of an impending health problem.30 These smart homes can assist the aged in maintaining a more independent life.

Several exemplars of smart homes are noted in literature: CAST—Center for Aging Services Technology—have developed several projects, including a home that integrates various sensors into its environment to monitor movement to help debilitated aged people track their normal activity and to provide alerts when non-normal living is detected, and a sensor-based bed that will track sleep patterns for later evaluation of possible diseases; the Center for Future Health has built a five room house with various infrared sensors, monitoring devices, and biosensors with the goal to provide users with the data they need to manage their health and to forecast changes in their living that could be the signs of an immediate or future health issue; and the MobiHealth^© project at Georgia Tech is working on a system for the remote collection of body signals, thereby allowing health professionals to more easily monitor patients in their homes.31

Challenges Ahead

While persuasive technologies have promise, formidable challenges lie ahead. Table 4 addresses the most common challenges.

The Future of Persuasive Technology in Health Care

The study of attitudes and persuasion remains a defining characteristic of contemporary social psychology.35 Over the last 70 years, attitude still remains a “most distinctive and indispensable” concept and “a prime factor that must be considered when reflecting on persuasion … Most accept the view that an attitude represents an evaluative integration of cognitions and affects experienced in relation to an object. Attitudes are the evaluative judgments that integrate and summarize these cognitive/affective reactions. These evaluative abstractions vary in strength, which in turn has implications for persistence, resistance, and attitude-behavior consistency.”35

Designers have to understand that processes of attitude formation and change are not identical, nor are their outcomes. Factors that do affect attitude change have been a staple of social psychology from its earliest days. The fundamental premise of attitude change says that messages are presented, processed, and if successful, move recipients attitudes toward the advocated position. The revised attitude, in turn, may influence subsequent behavior under appropriate conditions. The well-known dual-process model says that message reception can lead to attitude change and then behavior change. If receivers are able and properly motivated, they will elaborate, or systematically analyze, persuasive messages. If the message is well reasoned, data based, and logical (i.e., strong), it will persuade; if it is not, it will fail.

With the latest advancements in Internet and mobile communications technology, a number of avenues are available to help designers promote adoption of persuasive applications and technologies to their intended end-users. The success of the adoption of these technologies will depend on the grounded understanding of the theories above. This should become a fertile ground for providing persuasion toward healthy living. The time is right. Are the researchers, designers, health care providers, and patients ready for it?