Katherine Kim, M.P.H., MBA, iN Touch Principal Investigator, San Francisco State University
A meta-review by Webb, et al.² showed that Internet and mobile health interventions designed based on a behavioral theory resulted in better health outcomes with larger effect sizes than those that were not based on a theory. Of the studies included in the review, those that had used Aizen’s Theory of Planned Behavior were the most successful in improving health outcomes. Aizen’s Theory states that individual attitudes and social norms contribute to motivation. But, motivation alone is not sufficient to yield behavior change. There must also be an adequate level of perceived behavioral control which means the individual must think they possess the ability to make the change (and have the capability to make the change). Sounds good, but how do you actually design based on a theory?
For iN Touch, here’s how we thought about it:
For motivation, we needed to elicit individual attitudes/beliefs/values and reinforce positive social norms. The health coach drew out the participant’s individual attitudes through conversation and reinforced the values of health, well-being, and empowerment to make change. She also facilitated self-reflection about the ODLs and identification of trends and patterns in the combinations of ODLs. Weigh-ins and measurements were also a form of reinforcement by revealing objectively whether behavior changes each person made were effective or not. These contributed to motivation in an ongoing way.
We spent a great deal of effort designing perceived behavioral control, using both online and offline tools. The iN Touch application itself was a tool for behavioral control because it allowed the participant to capture the ODLs, review them in real-time, and conduct ad hoc comparisons. We designed the application within a "Five Clicks, Five Minutes" (per day) rule our Youth Advisory Board provided to minimize data entry burden (Sabee, et al.¹). Our post last month provided a detailed overview of the application. The iPod Touch device itself is portable and highly accessible, further contributing to perceived behavioral control.
Offline, we provided participants with a “My Experiment” tool for weekly goal setting and action planning. The key to this coaching tool is it provides the participant a way to make a short-term commitment, prepare for any obstacles, assess their level of confidence, and plan for follow-up. It gives them permission to try out a behavior change and have full control over the conduct of their experiment.
Finally, our intervention included multi-modal interaction with the health coach in order to provide support when and where the participant needed it, another way of putting control in the participant’s hands. Participants were able to meet with the health coach in person or by phone, during scheduled or drop-in appointments, and communicate via text message. All of these strategies contributed to perceived control by participants.
We used the theory of planned behavior to inform both design of the technology and programmatic elements. The use of health behavior change theory in technological design is still emerging. We are eager to hear about other examples where this has been applied. Please share your experiences with us in the comments.
¹ Sabee CM, Kim KK, Charles J, Logan H, Young E. (October, 2011). Five Clicks, Five Minutes: Providing a Voice for Youth with Obesity and Depression with a Mobile Health Platform. Manuscript presented at the International Conference on Communication in Healthcare: Chicago, IL.
² Webb TL, Joseph J, Yardley L, Michie S. (2010). Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. J Med Internet Res,12(1):e4). doi:10.2196/jmir.137.