Summary:

This project is in the process of utilising mobile persuasive technology, primarily mobile phones, to improve maternal health outcomes for Indigenous Australian woman.

This development has become possible due to a number of studies reporting on the rapid adoption of mobile phone technology by Indigenous Australian communities, within a very short timeframe (one to two years). In the USA, Russia, Africa and Ethiopia, similar systems are at various stages of development and testing.

Pregnant women using these systems have reported; improved interaction with healthcare providers, improved adherence to appointments and immunisations and increased access to health resources. The strength of these systems is their simplicity. Women receive 2-3 SMS text messages per week, timed to correspond with the woman's due date, with a focus on critical issues in maternal health, that experts want them to know.

While Australia has historically struggled to meaningfully progress with a national E-Health agenda, this proposal aims to investigate and develop a culturally appropriate pilot system, and to provide preliminary evidence that such a system would be effective in an Indigenous Australian context.

What is 'Persuasive Technology'?

The Preface of the Proceedings in First International Conference on Persuasive Technology, by Ijsselsteijn and others (2006) provides a definition of exactly what Persuasive Technology is, they explain,

'Persuasive technology is the general class of technology that has the explicit purpose of changing human attitudes and behaviours. Persuasive technologies apply principles of social psychology in influencing people; principles of credibility, trust, reciprocity, authority and the like. Social psychologists have spent a great deal of effort over many years in trying to understand how attitude and behaviour change comes about, focusing on the effectiveness of human persuaders, and the persuasive power of messages delivered through non-interactive mass-media, such as newspapers or television' (p. v).

'The scope of technologies that hold persuasive potential is broader than ICT alone, and includes persuasive product design and architectural design, yet the interactive nature of computers uniquely enables user-sensitive and user-adaptive responding, allowing persuasive messages to be tailored to the specific user in question, presented at the right place and at the right time, thereby heightening their likely persuasive impact'

(Ijsselsteijn, 2006, p. v).

Mobile Persuasive Technology

Until recently, most software applications and technologies were developed without much thought to how they influenced their users. This perspective is changing. Today, industry experts and academics are embracing a purposeful approach to persuasive design. In an industry context, designing for persuasion is becoming essential for success. In academic settings, the study of persuasive technology illuminates the principles that influence and motivate people in different aspects of their lives. (Oinas-Kukkonen 2008, p. v)

Persuasive technology is rapidly growing into a major discipline, sometimes referred to as captology or the study of computers as persuasive technologies (Oinas-Kukkonen 2008, p. v). Captology ‘… includes the design, research, and analysis of interactive computing products (computers, mobile phones, websites, wireless technologies, mobile applications, video games, etc.) created for the purpose of changing people’s attitudes or behaviours’ (Stanford Persuasive Tech Lab 2010a, n.p).

While a precise definition of persuasion is not agreed upon, for the purpose of this discussion, Persuasion is a ‘… noncoercive attempt to change attitudes or behaviours’ (Fogg, Cuellar, & Danielson 2007, p. 134). Behavioural change technology is an object of study within persuasive technology (Oinas-Kukkonen 2008). The use of mobile phones and text messaging as a platform for behavioural change is also relatively new, yet it has received significant research interest in recent years (Klasnja, Consolvo & Pratt 2011).

The potential of mobile phones for behaviour change applications is growing. To estimated the types of behaviour change most suited for mobile devices, Fogg (2009b) draws on his experience in the field of persuasive technology. Fogg believes both Blue and Purple behaviours (Figure 1.2) to be most suited for mobile persuasion. In particular, Blue Span, Blue Path, Purple Span and Purple Path.

Figure 1.2: The Behaviour Grid

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(Source: Stanford Persuasive Tech Lab 2010, p. 4)

There are two distinctive parts to ‘Purple Span’ behaviour changes. The ‘Purple’ part indicates a behaviour that is familiar to the target audience, they know the behaviour, its been achieved before. ‘There are no surprises in performing a Purple Behaviour. People know the costs (in time, money, effort, and so on). They also have a sense of the outcomes (either benefits or not)’ (Stanford Persuasive Tech Lab 2014, n.p). The only distinct facet of the ‘Purple’ behaviour is that it is preformed more intensely (Stanford Persuasive Tech Lab 2014).

The ‘Span’ part indicates a behaviour change that extends for a fixed period of time. The change is not done for only one-day (a ‘Dot’), neither is it a permanent change (a ‘Path’), it can last for three weeks, nine months, or two years. The period of time is irrelevant. The target audience knows the intensity of the behaviour has an end date (Stanford Persuasive Tech Lab 2014). For example, a ‘Span’ ‘… does not refer to working out for 30 minutes just one day. Instead, it would be working out, repeated for 14 days’ (Stanford Persuasive Tech Lab 2014, n.p).

Examples from the Stanford Persuasive Tech Lab (2010b, p. 5) of Purple Span Behaviour include:

To achieve Purple Span Behaviour, according to the Stanford Persuasive Tech Lab (2010b), it is necessary to either:

  1. Increase the number of triggers leading to the desirable behaviour.
  2. Enhance ability to perform the behaviour (make it easier to do)
  3. Amplify motivation for doing the behaviour with intrinsic and extrinsic motivators.

Fogg (2009, p. 4) provides further practical advice on completing this step:

'In practice, a persuasive technology solution will often require more than simply triggering a desired behaviour. Rather, the solution must also boost motivation or facilitate the behaviour, or both. If the target audience lacks only motivation, the persuasive design should focus on motivation. If ability is lacking, the solution should facilitate the target behaviour. One caution: If the target audience is lacking both motivation and ability, the team may want to back up and rethink the previous steps'.

Fogg (2009, p. 4).

Fogg (2009c) defines Motivation as containing three elements ‘… sensation, anticipation, and belonging’ (n.p), adding, that by ‘…manipulating any one of these dimensions, designers can manipulate motivation (n.p). These three core motivators are further broken down into two facets:

To clarify, Fogg (2009c, n.p) provides the following example:

'[I]n the case of stretching for 20 seconds, we did some early testing to find out if people wanted to perform this behaviour. Was the motivation already sufficient? The answer was “yes”. We learned that many people would welcome this stretching break in their busy lives. So for this intervention, we didn’t need to focus on motivation.'

Fogg (2009c, n.p).

Fogg defines Ability, explaining ‘…that a person must be able to perform the target behaviour’ (2009c, n.p). He cautions designers not to assume the target audience ‘… is more capable than they really are’ (2009c, n.p). Fogg (2009c, n.p) further explains there are two ways to increase ability:

'You can train people to have more skills. That’s the hard path: persuading people to learn new things. The better path is to make the target behaviour simpler to do. I have identified the six factors that affect simplicity as: time, money, physical effort, brain cycles, social deviances and non-routine. But you don’t need to know the six factors to understand my point: in most situations behaviour change occurs only when the behaviour is easy to do.'

Fogg (2009c, n.p).

The Trigger, as defined by Fogg, ‘…tells someone to ‘do it now’’ (2009c, n.p), it can ‘be a reminder, a deadline, among other things’ (2009c, n.p). He further explains,

'Technology interventions that require only a trigger are the easiest to create and the most likely to succeed. For example, in the stress reduction project, participants in our pilot needed only to be reminded to stretch. We didn’t need to motivate them to stretch, or teach them how. Any solution designed to change behaviours must orchestrate all three elements – Motivation, Ability, Trigger – coming together at one moment. The common mistake is to focus solely on motivation. But the path to success often is about increasing ability and triggering the behaviour (Fogg 2009c, n.p).'

Fogg (2009c, n.p).

The manipulation of triggers, ability and motivation at the same time is not recommended by the Stanford Persuasive Tech Lab. Manipulating motivation is considered last, manipulating ability considered second and manipulating triggers is considered first. The manipulation of triggers is the simplest to implement and often all that is required (Stanford Persuasive Tech Lab 2010).

Implementing these types of persuasive technology strategies for Indigenous Australian peoples has only recently become possible due to a number of studies reporting on the rapid adoption of mobile phone technology, by Indigenous Australian communities, (Taylor 2012; Kral 2010; Dyson & Brady 2009; DBCDE 2008; Tangentyere Council Research Hub and Central Land Council 2007; James 2006; Young et al. 2005; Tiwi Land Council 2004).

The literature further supports the use of mobile health messaging in the delivery of health care. (Stockwell et al. 2012; Whittaker et al. 2012; Cole-Lewis & Kershaw 2010; Fjeldsoe, Marshall & Miller 2009; Whittaker et al. 2009; Krishna, Boren & Balas 2008).

Health messages, delivered to mobile devices, has been used successfully to manage anxiety symptoms, (Riva et al. 2006) support smoking cessation, (Rodgers et al. 2005; Brendryen & Kraft 2008; Brendryen, Drozd & Kraft 2008) weight loss through diet or physical activity (Joo & Kim 2007; Hurling et al. 2007; Haapala et al. 2009; Patrick et al. 2009) and therapeutic communication for emotional disorders (Gerber et al. 2009; Haapala et al. 2009; Hazelwood 2008; Kharbanda et al 2009; Leong et al., 2006; Prestwich, Perugini, & Hurling 2009). Health care process interventions have included reminders to take medications (Mao, Zhang & Zhai 2008; Strandbygaard, Thomsen & Backer 2010; Miloh et al. 2009; Franklin et al. 2006; Vilella et al. 2004; Cocosila et al. 2009) and appointment reminders (Downer et al. 2006; da Costa et al. 2010; Koshy, Car & Majeed 2008; Liew et al. 2009).

Method

While the application of the current project is in the discipline of health, the projects foundation remains within the discipline of Human Computer Interaction. In other words, this is a HCI project, not a Health project. In the development of health behaviour change interventions, using mobile phones, Fjeldsoe and others note, ‘To date, few authors have reported on their intervention development methods, and published evaluations rarely provide the level of details required to replicate the intervention’ (2012, p. 151). This project intends to partly address this knowledge gap.

The behaviour message development process will be adapted directly from BJ Fogg’s (2009) paper, Creating Persuasive Technologies: An Eight-Step Design Process. Fogg’s (2009) model (Figure 1.2) is followed closely, providing a practical application of HCI in areas of cultural sensitivity. The eight-step process includes the best practices for early stages of persuasive technology design. Each of the steps are generally followed in sequence; at times, two steps can run in parallel, at other times, previous steps need to be re-thought and re-worked before proceeding. Fogg (2009) intended flexibility in the process, with each step representing a milestone, rather than a rigid step-by-step process. Adapting the sequence to the circumstances, according to Fogg, ‘… is a valid part of the design process’ (Fogg 2009, p. 2).

Figure 1.2: Eight steps in early-stage persuasive design model.

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(Source: Fogg, 2009, p. 3)

To date, the project has completed Step 6. The ethics application required to complete Step 7 is currently being finalised.

Innovation in Healthcare

The following video is a short (7 minute) presentation of this innovative health idea made to HarvardX, for the course 'Innovating in Health Care'. The Harvard Business School course required the development of a business plan and video. The following video is not going to win an academy award but it does manage to get the concept across.

Update (17 Jun. 2014): Out of seventy six teams, this video presenting an SMS persuasive technology approach to improving maternal healthcare, has progressed to the final eight.

Update (21 Jun. 2014): The idea came 7th (in the world). The judging criterium was 'Please vote for the one you think will do the most good and the most well'.

Figure 1.1: Example SMS Text Message.

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Other message examples are available from Text4Baby, a US based, free text messaging service based on behavioural theory. Text4Baby has a large subscriber base with more than 320,000 people enrolling between February 2010 and March 2012 (Whittaker et al. 2012). Messages cover the period from early pregnancy through to the baby’s first birthday. The text messages are very generic but provide helpful advice on maternal health options and alternatives. For example:

While these messages examples may appear short and simple, a study on SMS pregnancy health intervention by the California State University (2011) reported ‘…women like receiving health information via text messages, and will act upon the knowledge they receive’ (p. 2).

Ethics

For those who design, study, or use persuasive technologies, the examination of ethical issues is a key component. Ethical values vary from culture to culture so clear-cut global guidelines are unable to satisfy each case. Generally, persuasive design is ethical if the end-user gives permission for it, it is unethical if it is deceptive. End-users will willingly consent to an interactive system that tracks their progress and motivates them to do better. Especially when they know something is good for them but may not have the willpower to meet their goals.

While many examples are clear, where persuasive technology is used to make decisions for others, the ethics are less clear-cut. For example, teenage pregnancy is generally viewed by the mainstream Western culture as an important social problem worthy of intervention. Yet, this issue is not viewed as problematic across all cultures or in different historical contexts. Therefore, persuasive interventions require a careful cultural consideration of end-users context.

To address these issues, this project is being carried out in association with a reputable academic institution. Universities generally requires a formal ethics application to prevent any unintended abuse to research participants. The process becomes even more rigorous when involving pregnant participants. This process slows down the research but it protects both participants and researchers. Outside academic institutions, persuasive technology development goes largely unregulated.

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