From persuasion to negotiation in health promoting technology

Over recent years, designing technologies to promote health-related behavioural change has been an area of growing interest in HCI. Given the prevalence of self-monitoring and social facilitation in emerging designs, the assumption appears to be that increasing an individual’s awareness of his or her behaviour and the behaviour of others will promote behavioural change. This thesis argues that while this is true to some extent, this represents a somewhat naive view of how individuals come to make decisions regarding their health-related behaviours. Three qualitative studies within distinct health domains illustrate the complex nature of health-related behavioural change. Weight Management was an inherently social activity, albeit subject to selective disclosure and incremental participation. Individuals were generally motivated by appearance rather than health, implementing change based on exposure and orientation to alternative strategies. In Families at Risk, caregivers were highly motivated by a desire to safeguard the health of their children but were restricted by a lack of financial and strategic resources. Lack of trust and a transient community contributed to social isolation, thus inhibiting opportunities for collaboration. In Cardiac Rehabilitation, behavioural change efforts were prompted by an acute health crisis and guided by health professionals. However, behavioural change efforts were sometimes restricted by a desire to return to normal, tensions arising when what was considered normal was composed of risk behaviours. Family involvement varied greatly, ranging from disregard to facilitating change, and a desire for independence and ownership of the rehabilitation sometimes restricted the active involvement of peers. Informed by the findings of these studies this thesis highlights the strengths and limitations of current technological approaches to promoting behavioural change, provides implications for design, and supported by the sociomedical literature, identifies alternative avenues of technological innovation. The thesis reflects on technology’s role in health-related behavioural change and considers associated ethical implications. Overall, the main contribution of this thesis is a reframing of the problem of promoting health-related behavioural change as more than a matter of behavioural awareness and personal motivation. While it is understandable that technologists would look to the clinical domain to inform initial investigations in this area, this thesis argues that technologists should be cautious about blindly adopting its prescriptive paradigm. As an alternative to persuasion, this thesis offers negotiation as a potential model for future innovations in this area

When do we eat? An evaluation of food items input into an electronic monitoring application

We present a formative study that examines what, when, and how participants in a chronic kidney disease (stage 5) population input food items into an electronic intake monitoring application. Participants scanned food item barcodes or voice recorded food items they consumed during a three week period. The results indicated that a learning curve was associated with barcode scanning; participants with low literacy skills had difficulty describing food items in voice recordings; and participants input food items depending on when they had dialysis treatment. Participants thought this electronic self monitoring application would be helpful for chronically ill populations in their first year of treatmen

There's a monster in my kitchen: using aversive feedback to motivate behaviour change

In this paper we argue that “persuasive technologies,” developed to motivate behaviour change in users, have so far failed to exploit the established body of empirical research within behavioural science. We propose that persuasive technologies may benefit from both adapting to individual preferences, and a constructive use of aversive, in addition to appetitive, feedback. We detail an example application that demonstrates how this approach can be incorporated into an application designed to train users to adopt more environmentally friendly behaviours in their domestic kitchens

Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men

<b>Background</b><p></p> Obesity increases the risk of many serious illnesses such as coronary heart disease, type 2 diabetes and osteoarthritis. More men than women are overweight or obese in the UK but men are less likely to perceive their weight as a problem and less likely to engage with weight-loss services.<p></p> <b>Objective</b><p></p> The aim of this study was to systematically review evidence-based management strategies for treating obesity in men and investigate how to engage men in obesity services by integrating the quantitative, qualitative and health economic evidence base.<p></p> <b>Data sources</b><p></p> Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database were searched from inception to January 2012, with a limited update search in July 2012. Subject-specific websites, reference lists and professional health-care and commercial organisations were also consulted.<p></p> <b>Review methods</b><p></p> Six systematic reviews were conducted to consider the clinical effectiveness, cost-effectiveness and qualitative evidence on interventions for treating obesity in men, and men in contrast to women, and the effectiveness of interventions to engage men in their weight reduction. Randomised controlled trials (RCTs) with follow-up data of at least 1 year, or any study design and length of follow-up for UK studies, were included. Qualitative and mixed-method studies linked to RCTs and non-randomised intervention studies, and UK-based, men-only qualitative studies not linked to interventions were included. One reviewer extracted data from the included studies and a second reviewer checked data for omissions or inaccuracies. Two reviewers carried out quality assessment. We undertook meta-analysis of quantitative data and a realist approach to integrating the qualitative and quantitative evidence synthesis.<p></p> <b>Results</b><p></p> From a total of 12,764 titles reviewed, 33 RCTs with 12 linked reports, 24 non-randomised reports, five economic evaluations with two linked reports, and 22 qualitative studies were included. Men were more likely than women to benefit if physical activity was part of a weight-loss programme. Reducing diets tended to produce more favourable weight loss than physical activity alone (mean weight change after 1 year from a reducing diet compared with an exercise programme -3.2 kg, 95% CI -4.8 kg to -1.6 kg). The type of reducing diet did not affect long-term weight loss. A reducing diet plus physical activity and behaviour change gave the most effective results. Low-fat reducing diets, some with meal replacements, combined with physical activity and behaviour change training gave the most effective long-term weight change in men [-5.2 kg (standard error 0.2 kg) after 4 years]. Such trials may prevent type 2 diabetes in men and improve erectile dysfunction. Although fewer men joined weight-loss programmes, once recruited they were less likely to drop out than women (difference 11%, 95% CI 8% to 14%). The perception of having a health problem (e.g. being defined as obese by a health professional), the impact of weight loss on health problems and desire to improve personal appearance without looking too thin were motivators for weight loss amongst men. The key components differ from those found for women, with men preferring more factual information on how to lose weight and more emphasis on physical activity programmes. Interventions delivered in social settings were preferred to those delivered in health-care settings. Group-based programmes showed benefits by facilitating support for men with similar health problems, and some individual tailoring of advice assisted weight loss in some studies. Generally, men preferred interventions that were individualised, fact-based and flexible, which used business-like language and which included simple to understand information. Preferences for men-only versus mixed-sex weight-loss group programmes were divided. In terms of context, programmes which were cited in a sporting context where participants have a strong sense of affiliation showed low drop out rates and high satisfaction. Although some men preferred weight-loss programmes delivered in an NHS context, the evidence comparing NHS and commercial programmes for men was unclear. The effect of family and friends on participants in weight-loss programmes was inconsistent in the evidence reviewed - benefits were shown in some cases, but the social role of food in maintaining relationships may also act as a barrier to weight loss. Evidence on the economics of managing obesity in men was limited and heterogeneous.<p></p> <b>Limitations</b><p></p> The main limitations were the limited quantity and quality of the evidence base and narrow outcome reporting, particularly for men from disadvantaged and minority groups. Few of the studies were undertaken in the UK.<p></p> <b>Conclusions</b><p></p> Weight reduction for men is best achieved and maintained with the combination of a reducing diet, physical activity advice or a physical activity programme, and behaviour change techniques. Tailoring interventions and settings for men may enhance effectiveness, though further research is needed to better understand the influence of context and content. Future studies should include cost-effectiveness analyses in the UK setting

Nutrition-sensitive value chains from a smallholder perspective: A framework for project design

"The Alliance of Bioversity International and the International Center for Tropical Agriculture (CIAT) gratefully acknowledges permission from IFAD to re-publish that work as an Alliance Working Paper, with updated acknowledgements, author information and information on additional resources.

Enhancing Parent-Child Communication and Promoting Physical Activity and Healthy Eating Through Mobile Technology: A Randomized Trial

Background Although rates of pediatric and adult obesity remain high in the U.S., finding scalable and engaging ways to disseminate obesity prevention and treatment for families has been challenging. The purpose of the Motivating Families with Interactive Technology (mFIT) study was to test the feasibility, acceptability, and effectiveness of two remotely-delivered family-based health promotion programs for improvements physical activity (PA), healthy eating, and parent-child communication and relationship quality. Methods Parent-child (child age 9-12 years) dyads enrolled in a 12-week mobile intervention to increase physical activity and healthy eating, which included weekly email newsletters and the use of pedometers. Dyads were randomly assigned to one of two family-based programs, one of which utilized a mobile website and program materials that emphasized the importance of family interactions for health behavior changes. At baseline and 12 weeks, height and weight were measured by research staff, and participants completed web-based questionnaires about their dietary intake, family dynamics (e.g., parent-child communication), and experiences in the study. Results Dyads (n=33) were randomized (parents: 43+/-6 years, 88% female, 70% white, BMI 31.1+/-8.3 kg/m2; children: 11+/-1 years, 64% female, 67% white, BMI 77.6+/-27.8 percentile) and 31 (93.9%) provided complete follow-up data. Overall, there were no significant between-group differences in PA or dietary outcomes, but families significantly increased their average daily steps and servings of fruit during the intervention (marginally significant decrease in sugar-sweetened beverages) and had excellent adherence to self-monitoring protocols. Family functioning indicators were all high at baseline and most did not change significantly over time; none of the family dynamics variables were significant predictors of changes in average daily steps. Almost all parents (97%) and children (86%) said that they would recommend the mFIT program to a friend. Conclusions Dyads in the present study had high scores on family functioning variables at baseline, from both parent and child perspectives. Further research is needed to develop domain-specific measures of family dynamics, as well as to test familybased research with samples of families with more diverse baseline scores on family dynamics variables. Overall, the mFIT program showed excellent feasibility and acceptability as a low-cost, remotely delivered family intervention for physical activity and healthy eating promotion, and could serve as a dissemination model for similar public health interventions

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT.

BACKGROUND: Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor. OBJECTIVES: The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested. DESIGN: This was a three-arm, single-blind, parallel randomised controlled trial. SETTING: A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited. PARTICIPANTS: A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised. INTERVENTIONS: The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC. RANDOMISATION: Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation. MAIN OUTCOME MEASURES: The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. RESULTS: The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective. CONCLUSIONS: Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84864870. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London

Patient Welfare and Patient Compliance: An Empirical Framework for Measuring the Benefits from Pharmaceutical Innovation

The main goal of this paper is to develop an empirical framework for evaluating the patient welfare benefits arising from pharmaceutical innovation. Extending previous studies of the welfare benefits from innovation (Trajtenberg, 1990; Hausman, 1996), this paper unpacks the separate choices made by physicians and patients in pharmaceutical decisionmaking and develops an estimable econometric model which reflects these choices. Our proposed estimator for patient welfare depends on (a) whether patients comply with the prescriptions they receive from physicians and (b) the motives of physicians in their prescription behavior. By focusing on compliance behavior, the proposed welfare measure reflects a specific economic choice made by patients. We review evidence that the rate of noncompliance ranges up to 70%, suggesting an important gulf between physician prescription behavior and realized patient welfare. Since physicians act as imperfect but interested agents for their patients, the welfare analysis based on compliance must account for the nonrandom selection of patients into drugs by their physicians. The key contribution of this paper resides in integrating the choices made by both physicians and patients into a unified theoretical framework and suggesting how the parameters of such a model can be estimated from data.