Pervasive, Persuasive Health Challenges: Designing for Cessation of Use of the Intervention

A second area that has received too little attention is whether we, as designers, intend for people to stop using everyday health and wellness systems, and if so, what the optimal process for that is. In my own work (e.g., [1, 2]), I have focused largely on systems that people might use indefinitely, potentially for the rest of their lives. In doing so, I have focused on making applications that are simple and fast to use, so that people would have an easier time starting and continuing to use them. Given common issues and challenges with adoption and initial adherence, as well as reduced use after the novelty effect wears off, it is no wonder that this particular challenge has thus far received little attention. More cynically, another barrier to this issue receiving much attention is the competing interest of the individual and commercial application/system providers: an individual may prefer to some day no longer need an application, but it is potentially much more lucrative for companies to have a customer for life.

It is, nevertheless, important. First, there may be times when designing systems to support temporary use may actually help some of the initial adoption and adherence problems: people might be willing to put up with a tedious process or a somewhat intrusive device if an application promises to teach them new skills and then be gone from their lives. Second, if we consider what it is like to live with persuasive systems, how many of us would want people to have lives that are carefully regulated and nudged by a myriad of systems, until the day we die [3]? And finally, might some persuasive health systems create an effect of learned helplessness in which applications, assuming the role of determining and recommending the most appropriate choices, actually reduce individualsā€™ competency to make these decisions in the absence of that support?

Anecdotally, many researchers have described high recidivism rates after the conclusion of an intervention, when the fitness sensor or diary, or the calorie counting tool, is no longer available to the former subjects (this has been observed with other types of interventions as well [4]). Why are these applications not helping individuals to develop good, robust fitness habits or competencies for health eating and at least keeping approximate track of calories? Would a study actually find worse post-intervention health habits among some participants?

To help imagine what we might build if we had a better understanding of how to create temporary health and wellness interventions, consider Schwanda et al’s study of the Wii Fit [5]. Some stopped using the system when it no longer fit into their household arrangement or routine, others when they had unlocked all of the content and its activities became boring or repetitive, and others stopped using it because they switched to another, often more serious, fitness routine. From a fitness perspective, the first two reasons might be considered failures: the system was not robust to changes in life priorities or in living space, or it suffered a novelty effect. The third, though, is a fitness success (though possibly not a success for Nintendo, if the hope is that they would go on to buy the latest/greatest gaming product): participants “graduated” to other activities that potentially were more fulfilling or had still better health and wellness effects. Imagine if the design of the system had helped more users to graduate to these other activities before they became bored with it or before it no longer fit into their daily lives.

Returning to the examples of exercise and calorie diaries, what changes might make them better at instilling healthy habits? In the case of a pedometer application, could it start hiding activity data until participants guessed how many steps that had taking that day? Would such an interface change help people learn to better be aware of their activity level without a device’s constant feedback? What if, after some period of use, users of calorie counters started not getting feedback on the calories they had consumed per food until they end of the day? Would such activities support development of individuals’ health competencies better than tools that offer both ubiquitous sensing and feedback? How would such changes affect the locus of control and sense of self-efficacy of applications’ users?

These are some rough ideas ā€“ the medical community, perhaps because of a focus on controlling costs and/or lower ability to integrate the interventions they design into daily life, has more history of evaluating interventions for the post-intervention efficacy (e.g., [6], [7]). Other communities have deeper understanding of what it takes to develop habit (e.g., [8], [9]) or to promote development. What does the HCI community stand to learn from these studies, and to what extent should or community conduct them as well?

  1. Munson SA, Consolvo S. 2012. Exploring Goal-setting, Rewards, Self-monitoring, and Sharing to Motivate Physical Activity, Pervasive Health 2012. [pdf]
  2. Munson SA, Lauterbach D, Newman MW, Resnick P. 2010. Happier Together: Integrating a Wellness Application Into a Social Network Site, Persuasive 2010. [pdf]
  3. Purpura S, Schwanda V, Williams K, Stubler W, Sengers P. 2011. Fit4Life: The Design of a Persuasive Technology Promoting Healthy Behavior and Ideal Weight, Proceedings of CHI 2011. [pdf]
  4. Harland J, White M, Drinkwater C, Chinn D, Farr L, Howel D. 1999. The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care, BMJ 319: 829-832. [pubmed]
  5. Schwanda V, Ibara S, Reynolds L, Cosley D. 2011. Side effects and ‘gateway’ tools: advocating a broader look at evaluating persuasive systems, Proceedings of CHI 2011. [pdf]
  6. Bock BC, Marcus BH, Pinto BM, Forsyth LH. 2001. Maintenance of physical activity following an individualized motivationally tailored intervention, Annals of Behavioral Medicine 23(2): 79-87. [pubmed]
  7. Moore SM, Charvat JM, Gordon NH, Roberts BL, Pashkow F, Ribisl P, Rocco M. 2006. Effects of a CHANGE intervention to increase exercise maintenance following cardiac events, Annals of Behavioral Medicine 31(1): 53-62. [pubmed]
  8. Rothman AJ, Sheeran P, Wood W. 2009. Reflective and Automatic Processes in the Initiation and Maintenance of Dietary Change, Annals of Behavioral Medicine 38(S1): S4-S17. [pdf]
  9. Verplanken B. 2010. Beyond Frequency: Habit as Mental Construct,
    British Journal of Social Psychology 45(3): 639-656.