Health Promotion: Patient Self-Management, Cognitive Work Analysis, and Persuasive Design
School of Information Sciences University of Illinois at Urbana-Champaign
Department of Systems Design Engineering University of Waterloo
The patient work of self-management is composed of self-activation, planning, and maintenance of a variety of health promotion behaviors, such as health information and service seeking, medication adherence, symptoms management, decisionmaking, and health habit formation (e.g. diet, physical activity (PA)) (Bodenheimer, 2002). These health promotion behaviors are complex and challenging, thus requiring significant cognitive resources and skills (Rich et ah, 2015; Schwarzer et ah, 2011). Hence, designing sociotechnical solutions to ease patients’ demands and support patient self-management is important for patients’ health promotion.
Human factors and ergonomics methods focus on analyzing current sociotechnical systems and enhancing their safety and efficiency (Vicente, 1999). Persuasive design may be seen as complementary, emphasizing behavioral change with the understanding that those behaviors help people reach longer-term goals (Fogg, 2009). The goal of this chapter is to bridge theories in health promotion, persuasive design, and a particular human factors and ergonomics method, cognitive work analysis (CWA), to demonstrate the potential approach to design new sociotechnical solutions for longterm health promotion. In this chapter, we w ill introduce: (1) theoretical foundations of health promotion, (2) the applications of persuasive design to health promotion, (3) the use of CWA to inform the persuasive design for health promotion, and (4) the implications of future w'ork at this intersection for health promotion.
Health Promotion Models
Health promotion models aim to explain and predict the processes and factors contributing to the change of existing behavior or adoption of new behavior. Such change encompasses the formation and stabilization of intentions, as well as the planning, adoption, and maintenance of the behavior. In this section, we describe six prominent health promotion models, which highlight the role of a range of processes and factors of behavior change (see Table 11.1 for a summary).
Health Belief Model
The Health Belief Model (HBM) explains the adoption of health behavior based on six factors related to risk assessments of both the threats to prevent and the preventive (health) behavior to adopt. The six factors include: (1) perceived susceptibility; (2) perceived severity of the threats to prevent; (3) motivations; (4) perceived benefits; (5) perceived barriers to adopt the prevention behavior; and (6) the cues to action (Janz & Becker, 1984; Rosenstock, 1974). For example, one study showed that the HBM can be used to explain the influenza vaccination behavior among adults, in that the likelihood of vaccination will increase if the perceived susceptibility to disease increases (Weinstein et al., 2007). Furthermore, meta-analyses have suggested that the HBM is able to explain the adoption of short-term health behavior such as cancer screening, medical test, and exam adoption (Carpenter, 2010; Harrison et al., 1992).
Theory of Planned Behavior
The Theory of Reasoned Action (Ajzen, 1985; Ajzen & Fishbein, 1977) emphasizes the crucial and immediate role of behavioral intentions to adopt a new' behavior.
The Theory of Planned Behavior (Ajzen, 1991) further suggests that the behavioral intention is shaped by attitudes (the beliefs about the positive or negative consequences of the behavior), subjective norms (the motivations and beliefs to comply with the behavior from other peers and social norms), and perceived behavior control (the beliefs of control over one’s behavior). The theory of planned behavior has been used to explain the adoption of health promotion behavior, such as PA (Hausenblas et ah, 1997), smoking cessation (Тора & Moriano Leon, 2010), HIV prevention (Albarracin et ah, 2001), and chronic illness treatment adherence (Rich et ah, 2015).
Social Cognitive Theory
The Social Cognitive Theory (Bandura, 1977, 1989; Schwarzer, 2001; Schwarzer & Renner, 2000) explains and predicts the changes of attitudes or behavior depending on the beliefs about the self to perform certain tasks or behavior, also called self- efficacy. Regardless of the levels of actual competence, the social cognitive theory suggests that an increase of self-efficacy could lead to increasing likelihood to adopt a behavior. In addition to self-efficacy, outcome expectancies are critical to the adoption of behavior: (1) action-outcome expectancy, the beliefs about the consequences resulted from the action; and (2) situation-outcome expectancy, the beliefs about the consequences resulted from other external environmental factors. Social cognitive theory proposed that the new behavior will be adopted if someone perceives control over their behavior, fewer external barriers, and more self-efficacy. Well-established evidence has shown the importance of self-efficacy and outcome expectancy in various health promotion behaviors, such as promoting quality of life and lifestyle change among cancer patients (diet and PA) (Graves, 2003; Stacey et al., 2015), promoting PAs (Young et al., 2014), and smoking cessation (Gwaltney et al., 2009).
Protection Motivation Theory
The Protection Motivation Theory suggests that emotional appraisal (fear appeals) and reliance on the avoidance of harmful consequences of maladaptive behavior (smoking, binge drinking) are effective in changing the attitudes or intentions as related to health behavior adoption. The avoidance of harms is driven by three cognitive appraisal processes: perceived severity of the depicted harmful events, perceived vulnerability to a threat, and perceived effectiveness of the health behavior. The avoidance of harms, along with self-efficacy, is relevant to the intention to adopt health behavior (such as PA promotion, reduction of smoking behavior) (Maddux & Rogers, 1983; Prentice-Dunn & Rogers, 1986; Wurtele & Maddux, 1987; Floyd et al., 2000; Milne et al., 2000). For example, Pechmann et al. (2003) adopted protection motivation theory to analyze antismoking advertisements and suggested that using certain message themes, such as stressing the smoking-related consequences of endangering others, could increase the nonsmoking intentions of adolescents (Pechmann et al., 2003).
The Transtheoretical Model defines behavior change as a process involving five stages, each associated with different levels of preparedness, intentions, and likelihood of behavioral change (Prochaska & DiClemente, 1982). These stages are qualitatively different. People at different stages will act differently and require different interventions to move closer to their goals. The five stages of behavior change are: (1) precontemplation, in which people have no intention to change within the next 6 months; (2) contemplation, in which people have intentions to change within 6months; (3) preparation, in which people are ready to initiate changes; (4) action, in which people have just made a change in their health behavior within the past 6 months; and (5) maintenance, in which people made changes to their health behavior more than 6 months prior and are engaging in self-regulation to avoid relapse. Previous research has applied this model to design tailored communication and strategies at different stages of change for various health promotion behaviors, such as PA promotion, weight loss, smoking and substance cessation, cancer screening adoption, and HIV prevention, among others. (Hutchison et al., 2009; Marshall & Biddle, 2001; Mastellos et al., 2014; Prochaska & DiClemente, 1983; Prochaska et al., 1994; Spencer et al., 2002, 2005; Sutton, 2001).
Health Action Process Approach
The Health Action Process Approach divides patient self-regulated health promotion behavior into a pre-intentional phase (i.e. how individuals become motivated to change the behavior) and a post-intentional phase (i.e. how to maintain and regulate the behavior) (Schwarzer et al., 2011; Sniehotta et al., 2005). In the pre-intentional phase, action self-efficacy (i.e. how well people think they can carry out the health behavior), outcome expectancy (i.e. the expected consequences of adopting the behavior), and risk perceptions of the threats for not adopting this health behavior jointly affect the formation of intention. Once intention is stabilized, people then enter the post-intentional phase to decide where and when to adopt the new behavior. In order to translate the intention to behavior, there is a planning process. Planning includes (1) conducting detailed action planning to form the mental model to carry out the behavior (Lippke et al., 2004), and (2) coping planning, which is a self- regulatory process to avoid relapse for the prolonged pursuit of goals (Lippke et al., 2004; Schwarzer, 1999). Volitional, maintenance, and recovery self-efficacy (i.e. perceived competence to start the new behavior, continue the new behavior, and avoid relapse) jointly affect the planning process (Schwarzer & Renner, 2000). Compared to the Transtheoretical Model, the Health Action Process Approach proposed the “planning” process which is critical to fill out the intention-behavior gap. The Health Action Process Approach has shown some success to explain the adoption and longterm maintenance of health promotion behavior (e.g. rehabilitation, PA, lifestyle change) among various populations (e.g. patients with chronic illness, obesity and multiple sclerosis, pregnant women) (Chiu et al., 2011; Gaston & Prapavessis, 2014; Parschau et al., 2014; Schwarzer et al., 2011; Zhang et al., 2019).
Comparison of Model Types
Although the continuum models (HBM, Theory of Planned Behavior, Social Cognitive Theory, and Protection Motivation Theory) each showed slightly different advantages to explain and predict different kinds of health promotion behaviors, they generally showed better success in explaining and predicting the formation of behavioral intentions and the adoption of certain health behaviors than stage models (such as vaccination uptake, medical tests, or exam use). However, the effectiveness of these models to predict long-term behavior change and habit formation has been mixed (such as in the cases of PA, diet change, treatment adherence). In contrast, the stage models (Transtheoretical Model and Health Action Process Approach) showed better success in addressing the intention-behavior gap, maintaining the behavior change, and supporting the formation of new habits. Despite different strengths, however, these two types of models are not exclusive. Stage models have adopted factors proposed in continuum models to explain and predict behavioral change processes (e.g. self-efficacy in Social Cognitive Theory, perceived severity and vulnerability of the threat in HBM and Protection Motivation Theory as risk perceptions, and subjective norm in Theory of Planned Behavior). Hence, depending on the kinds of health promotion behaviors and the goals of the patients (whether increasing motivations or adopting a new behavior), a combination of health promotion models may be useful in informing the design of sociotechnical solutions to promote preventive health behaviors.