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Health behavior models in the age of mobile interventions: are our theories up to the task?

I recently read “Health behavior models in the age of mobile interventions: are our theories up to the task?,” by Riley, Rivera, Atienza, Nilsen, Allison, and Mermelstein, which appeared in March’s Translational Behavioral Medicine. The authors review papers, up to 2010 and as indexed by MedLine, that assess mobile health interventions and report at least some clinical outcome.

For each paper, the authors note the theories (if any) that were cited as guiding the development of the intervention. Most common were Theory of Planned Behavior, the Health Belief Model, Self-Determination Theory, Social Cognitive Theory, Self-Regulation Theory, the Transtheoretical Model, and cognitive-behavioral theory. The authors find that these theories are somewhat lacking for their ability to to guide the use of the affordances of mobile technology. In particular, theories based on linear progression tend not to take full advantage of mobile devices’ abilities for context awareness (through sensing and prompted input), increased variation in timing and content of interventions, and real-time awareness of outcomes.

While the health behavior theories may not be up to the task on their own, there are theories from a variety of disciplines that can guide, and are guiding, intervention designers. The authors suggest looking to control theory to address some of the shortcomings they identify, and offer a couple of interesting examples. The HCI and social computing community, which knows interactive systems and technology mediated social interaction, also has quite a bit to offer. Though HCI often borrows or adds to theories from other disciplines — including from the health community — it has developed quite a bit of expertise about how to implement these in systems, and developed its own applicable frameworks, such as the Reader to Leader Framework.

The way the authors found the literature they reviewed — a search of Medline — highlights a bit of a communication gap between these disciplines. No papers from HCI conferences or journals were included in this review, despite work such as UbiFit, MAHI, and Fish’n’Steps being excellent examples of the type of studies the authors reviewed. The authors are not alone in excluding HCI papers from review articles on this topic (e.g., [1], [2]). I agree, to a large extent, with Klasnja et al that deep understanding of users’ experiences with behavior change strategies, as implemented in a system, is one of the primary contributions HCI make can to this health behavior change work. Stopping at such findings, however, may be insufficient for the results to have an impact outside of the HCI community, much as eco-feedback work in HCI has not always reached beyond the HCI community.

Collaborations between the HCI and health communities, such as UCSD’s Center for Wireless & Population Health Systems, the iMed group at UW, or Northwestern’s newly announced Center for Behavioral Intervention Technologies, as well as boundary spanning venues such as WISH, Health 2.0, or the Designing for Healthy Living special issue of IJMI, are helping to close some of the gap between communities. We should, however, keep asking whether this will be enough.

We should also keep asking what might be on a research agenda that combines the strengths of HCI and health behavior change communities (or at least, I should, since I have a dissertation to write), with an eye toward advancing both theory and practice. Some thoughts:

  • What are appropriate ways to elicit social support or social pressure from others on social network sites or other technology mediated spaces?
  • When does anonymity support people trying to make healthy behavior changes, such as by helping them feel comfortable sharing, and when it is a barrier to making those changes, such as by reducing accountability?
  • Are some types of nudges that work once or in non-discretionary use problematic over the long term, such as because people start avoiding the system and aversive feedback?
  • How can we most effectively use leaderboards to support behavior change and maintenance? With data from many people, there are many more options for how to construct leaderboards than in smaller groups. For a given behavior or set of people, which comparison direction(s) and dimensions of similarity are most effective?
  • How applicable are health behavior change theories to other behavior change domains, such as eco-feedback? Where do the existing theories apply, where do they break? We already see things like the health belief model being applied to computer security practices.
  • As features used to nudge or support decision making become more widely adopted, do some feature remain effective or become like infrastructure while others become less effective?
  • What are the privacy implications of integrating sensing, storage, and sharing of of data? Is HIPAA policy even up to this task?
  • When do behavior nudges become coercive? What are good practices for ethics of these interventions? While many counseling strategies promote autonomy and intrinsic motivation as both a matter of efficacy and ethics, does this balance shift as devices that allow constant and long term monitoring (and thus control) become available? For example, some people can already save money on their insurance by agreeing to wear a pedometer and meeting certain step goals.

These are by no means completely open questions. Researchers and practitioners in both communities have been tackling many of them and making progress. It is also by no means a complete list.

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