=Paper=
{{Paper
|id=Vol-1369/Paper_1
|storemode=property
|title=Triggers in the Environment: Increasing the Reach of Behavior Change Support Systems by Connecting to the Offline World
|pdfUrl=https://ceur-ws.org/Vol-1369/Paper_1.pdf
|volume=Vol-1369
|dblpUrl=https://dblp.org/rec/conf/persuasive/LuddenO15
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==Triggers in the Environment: Increasing the Reach of Behavior Change Support Systems by Connecting to the Offline World==
https://ceur-ws.org/Vol-1369/Paper_1.pdf
7 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
Triggers in the environment
Increasing reach of Behavior Change Support Systems by
connecting to the offline world
Geke D.S. Ludden & Marleen Offringa
University of Twente, Faculty of Engineering Technology, Department of Product Design, De
Horst, Drienerlolaan 5, 7522NB, Enschede
g.d.s.ludden@utwente.nl, marleenoffringa@gmail.com
Abstract. Behavior Change Support Systems (BCSS) are a category of persuasive systems
that can potentially help large groups of people to change their behavior. Within this category,
many systems have been introduced aimed at helping people to lead a healthier lifestyle. How-
ever, many such systems do not reach all people that could benefit from using them. With ref-
erence to Stages of Change theory, this article discusses why current approaches to increase
reach have been less than successful. Further, we provide an alternative approach to increase
reach; design for stages of change. Following this design approach, we argue that triggers in the
environment can increase reach for BCSS. A case study serves as an example of how designers
can design interventions following the approach while connecting triggers in the environment
to BCSS. A preliminary user study showed that connecting a BCSS to a trigger in the environ-
ment is a promising avenue to increase reach. In our discussion, we will elaborate on future
avenues for research on triggers in the environment and the design of dynamic interventions.
Keywords: persuasion, stages of change, BCSS, reach, design
1 Introduction
Behavior change support systems (BCSS) have been introduced as a key construct for
research on persuasive systems design, technologies, and applications (Oinas-
Kukkonen, 2010). As a possible response to the severe problems that our society faces
when it comes to securing health for the public at large, many of such systems have
been introduced that aim to help people to adopt a healthier lifestyle. Among these
are, for example, systems that aim to improve dietary behavior or to increase the
amount of physical activity that people take every day (e.g., Consolvo et al., 2008).
BCSS can potentially be used by large groups of people because they are easily ac-
8 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
cessible, not overly expensive and mostly convenient to use. However, BCSS often
suffer from a lack of reach: most BCSS reach a limited group only, in many cases
mainly highly educated women (Kelders et al., 2011), suggesting that, that in spite of
their large potential, web-based interventions miss out on helping the public at large.
This selective reach is not intended and in many cases it seems to strengthen the ‘in-
verse care and information law’ (i.e. people in urgent need for care are the ones who
are least likely to receive care (Eysenbach, 2000; Tudor Hart, 1971).
Attempts to increase reach of BCSS have often followed the strategy of personaliza-
tion. Personalization of the content or of the aesthetics of a BCSS offers opportunities
to attract different target groups. The BCSS Chick clique, for example, (Toscos et al.,
2006) was designed especially to be attractive (in content and system to teenage girls.
Personalization can also be used to adapt the BCSS to the needs of different groups of
people. Kaptein et al, (2012) for example, measured susceptibility to persuasion and
studied effects of tailored, persuasive text messages to reduce snacking. Results
showed that tailored messages lead to a higher decrease in snacking consumption.
Personalization of a systems functionalities and content can thus attract different tar-
get groups and improve people’s satisfaction with services. In this paper, we would
like to introduce an alternative design approach to increase reach: that of placing trig-
gers in the environment. In his behavior model for persuasive design, BJ Fogg (2009)
mentions triggers as one of the three principal factors that are essential for a behavior
change to happen. In their work on Persuasive Systems Design, Oinas-Kukkonen &
Harjuuma (2009) postulate that persuasion is often incremental and that it is easier to
initiate people into doing a series of actions through incremental suggestions. We see
triggers as doing just that; A trigger can be a first reason to start a series of actions
leading to behavior change. Using theory on stages of change, we will show that most
BCSS currently attract people who are already to some extent motivated to change,
thereby failing to reach the large groups of people who are unaware of a need for
change. We will argue that placing triggers in the environment can be a successful
strategy to reach these groups of people. The paper will go on to show a design case
study that introduces a range of products that are connected and that help people
move through the different stages of change. We will report on a preliminary user
evaluation of this case study that indicates that placing a triggers in the environment
and connecting this trigger to a personal BCSS is a promising strategy to increase
reach.
2 Design for stages of change
In their work on health behavior change, Prochaska and colleagues (Prochaska et al.,
1992; 1997) identified 10 distinct processes of change. When they presented these
processes to their research participants, these reported that they used different pro-
cesses of change at different times, thus revealing that behavior change follows a
series of stages. These findings eventually led to the development of the Transtheoret-
ical Model of Health Behavior Change (TTM). Prochaska et al. suggest that to make a
durable health change, whether it is to quit smoking, to eat a more healthy diet or to
increase physical activity, people pass through five stages: precontemplation, contem-
9 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
plation, preparation, action and maintenance. In the first three stages, people built
motivation to change and in the last two stages people act. Following this theory,
health interventions should have different goals for people who are in different stages
of change. While interventions aimed at early stages of change should aim to raise
awareness, interventions in later stages should be more focused on acting out and
sustaining new behavior. Based on an analysis of health interventions aimed at eating
a healthier diet or at increasing physical activity, a framework was created for the
design of stage-matched interventions (Ludden & Hekkert, 2014). This framework
(see Figure 1) is largely based on the TTM, including processes of change and stages
of change while connecting these to design strategies for stage-matched interventions.
Four types of design strategies have been defined that adhere to four different (design)
aims: ‘raising awareness’, ‘enabling’, ‘motivating’ and ‘fading out’. As can be seen
from Figure 1, the design strategies spread over multiple stages.
Fig. 1. The ‘design for healthy behavior framework’ connecting processes and stages
of change to design strategies.
Most BCSS focus on particular phases in a behavior change cycle; that of action and
motivation. However, when it comes to leading a healthier lifestyle, many (most)
people are in earlier stages of change (Kramish Campbell et al., 1999). Most likely,
these people will not feel the need to buy or use any of the numerous devices or appli-
cations on the market that support adopting a healthier lifestyle.
Therefore, placing triggers in the environment, that everyone can (and will) en-
counter are essential to adopt BCSS and to start a process of change. People need to
become aware of the consequences of their choices and, as a second step, they need to
be made aware of their possibilities for action. While presenting a design case, we
will show how a trigger in the environment can serve as an enabler of changes to-
wards a healthier lifestyle.
10 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
3 Design case: sugar to water
A design case was carried out to serve as an example of how to design an intervention
that people come across in their physical environment as a trigger that is connected to
another, more personal intervention that uses a BCSS that can be used in later stages
of change. The topic for this design case was the lifestyle issue of drinking too many
sugar containing beverages. For many people, their daily intake of sugar is too high
which has a negative effect on their general health and wellbeing. Limiting the intake
of sugar containing beverages can be a solution to this problem. Of course, we are not
the first to address this lifestyle issue. There have been multiple attempts at creating
environmental interventions to raise awareness of this issue (and thus addressing ear-
lier stages of changes). These have often taken the form of posters or information
boards that are placed in public environments such as schools or governmental build-
ings. Environmental interventions such as these may indeed raise awareness of the
lifestyle issue. However, they do not support people in taking a next step in the behav-
ior change process. Subsequently, in a small but promising study, Langrial & Oinas-
Kukkonen (2012) have demonstrated that persuasive software using reminders may
help people to reduce their intake of ‘fizzy drinks’. However, the form of their inter-
vention was especially suitable for people in the action phase. In fact, while recruiting
respondents, these researchers specifically asked people if they were willing to reduce
their intake of fizzy drinks. This study showed promising results but does not solve
the problem of persuading people in earlier stages of change to decide to take the step
to change. A sequential intervention (addressing multiple stages of change) could
therefore be more effective in addressing this lifestyle issue.
Following the ‘design for healthy behavior framework’ three different products were
designed for three different phases of behavioral change. The connected products that
resulted from the design case were evaluated in a preliminary user study. Results from
this study will be discussed.
3.1 Design and stages of change
The first product was designed to match the motivational state of people in early stag-
es of behavior change. For this stage, two important issues have to be addressed. First,
people in this stage do not want to change, and, therefore, they will not be willing to
buy a product that supports a behavioral change. Second, the product should incorpo-
rate a design strategy aimed at raising awareness. During the idea generating phase,
several ways of distributing information at low cost were explored such as stickers
and (foldable) leaflets. Eventually, it was decided to choose a product that would be
seen as a more valuable item (and that would therefore less easily be discarded). The
product that was designed for this phase was a cooling sleeve that displays the amount
of sugar that different types of beverages contain (see Figure 2). The cooling sleeve
would be available as a free gift that could be handed out to people on the street. The
print on the sleeve contains a QR code that connects to a mobile application that was
designed to support a second phase of behavior change.
11 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
Fig. 2. Product designed for stages (pre)contemplation: a cooling sleeve with infor-
mation about sugar in beverages.
To develop the product that should support the next stage of change, that of prepa-
ration, the designer of the intervention incorporated a design strategy aimed at ena-
bling. To move through this stage people need to move from raised awareness to ac-
tually acting on a desired behavior change. During this phase, people have to come to
realise that they should and that they are able to change their behavior. Therefore, it is
important that an intervention can provide advice or possible actions that are relevant
for a specific person to enable his or her to take action. In such a situation, a BCSS is
a valuable solution because it allows organization of data and personalized feedback
(cf. Oinas-Kukkonen & Harjuuma (2009)). To make the BCSS easily accessible, we
chose to design a mobile application. The application supports people in tracking their
daily intake of sugar containing beverages and gives them personal advice on how
they can best change their daily habits, thus enabling them to take the next step to-
wards the desired behavior change. Figure 3 and 4 show a sequence of screen shots
that demonstrate the subsequent steps in the application; after adding some personal
information, users provide information about the drinks that they drink for a week.
During the week, they can gain view statistics to gain insight in precisely which bev-
erages that they normally drink contain most sugar. After a week, the application
creates personal advice and recommendations based on the provided data to support
the user to take the step into an action phase. In this phase, people actually implement
the behavior change based on the recommendations of the application.
12 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
Fig. 3. The image on the left shows a screen shot of the mobile application on the first day
where someone starts adding beverages from the menu to her daily intake. The image on the
right shows a second screen in the same menu with different beverages.
Fig. 4. Two more screenshots show the application after someone has added the daily intake of
beverages for at least four days. The image on the left shows statistics that give a user insight
into the types of drinks that have been consumed week. The screen shot on the right shows
personal advice on how best to change behavior.
13 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
Finally, the system could recognize from the behavior pattern that the user is ready to
take yet another step in the behavior change process: towards the stage of mainte-
nance and recommends the product that that links to the third phase. The product that
was designed for this third and last phase incorporated a design strategy aimed at
motivation. The best alternative for drinking sugar containing beverages is drinking
water. Therefore, a variety of alternatives was explored that motivate people to drink
water, including light indicators and timers. Eventually, we chose a less intrusive
solution because such a solution is less likely to cause irritation. The product for the
designed for the third phase was a water bottle that supports the achieved behavior
change by using an hour glass to remind the user to drink water (see Figure 5).
Fig. 5. Product designed for maintenance stage: incorporated design strategy aimed at motiva-
tion. The hour glass that is incorporated in this bottle reminds people to drink enough water.
3.2 Evaluative user study
To test whether the sequential intervention that was designed and that consisted of a
set of connected products could be effective in supporting people to move through the
different stages in a behavior change process we set up a preliminary user study. This
user study had two main aims. The first aim was to find out if the first product in the
sequence was effective for people in the early stages of behavior change and thus, if it
was effective in creating awareness of the lifestyle issue of drinking too many sugar
containing beverages. The second aim was to test whether the first product in the
sequential intervention was effective as a trigger to connect to products in later stages
of change.
14 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
Method.
The first product in the designed sequence, the cool sleeve was handed out to 18 re-
spondents (age 25-60, m = 34.3, 9 female). Respondents were randomly selected but
we tried to find respondents from multiple age groups and we tried to invite both men
and women. Because the second product in the sequence, the personal application was
not yet available we created a movie explaining the application and placed it on a
website. Attached to the cool sleeve was a card that had a text, a URL linking to the
movie and a QR code linking to the URL printed on it. The text on this card read:
“KNOW YOUR BEVERAGES. Are you curious to find what you sugar intake
through beverages is? Scan the QR code or visit the URL.” After three days, the par-
ticipants were asked to fill out a questionnaire asking questions about how they evalu-
ated receiving the cool sleeve (“I liked receiving the sleeve”), whether they had no-
ticed the information on the cool sleeve and whether this information had raised their
awareness of the amount of sugar in beverages (“The information on the sleeve made
me more aware of sugar in drinks”). We also asked whether they had visited the web-
site to see the movie and (if yes,) whether the video made them think of the amount of
sugar they consume through beverages and whether they would be interested in using
the application that was presented in the movie. Questions were either yes/no ques-
tions or were asked on 7 point scales with end points “do not agree at all” and “agree
completely”. At the end of the questionnaire participants were asked to provide addi-
tional comments.
Results.
Receiving a gift like this was something positive for almost all respondents, only two
people noted that they weren’t certain about if they would ever use the sleeve. Re-
sponses to the question that asked whether they had seen the information on the
sleeve were clearly positive (m = 6.3). Also, respondents noted that the information
on the sleeve made them more aware of the amount of sugar in beverages (m = 5.3).
General remarks revealed that in general respondents became more aware of sugar in
drinks after reading the information on the sleeve. Some of the participants noted the
fact that they already mostly drank water, tea and other drinks without sugar. Howev-
er, the large amount of sugar in some beverages seemed to surprise all of them.
Out of the 18 participants, 15 eventually visited the linked web page and watched the
video about the personal mobile application. Participants generally responded posi-
tively to the question about whether the video made them think about the amount of
sugar they consume through beverages (n = 15, m = 5.0). Also, participants indicated
that they were interested in the free application that would allow them to track the
amount of sugar they consume through drinking beverages (n = 15, m = 6.6).
Discussion.
First of all, the free cool sleeve that we handed out in this preliminary user study
clearly was effective in raising awareness of the lifestyle issue of drinking sugar con-
taining beverages. People were pleased to receive the sleeve and they all noticed the
information on the sleeve. The fact that all respondents took notice of the information
is a very positive result: it may be easy to hand out free gifts, but raising awareness
15 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
through such a free gift is another step. Our results show that for almost all respond-
ents their awareness of sugar in beverages was raised. Out of the 18 participants, 15
eventually watched the video, which indicated that they became interested in the sub-
ject of sugar in beverages. Again, most of the participants noted that the video in its
turn raised their awareness of the issue. Moreover, the larger part of our participants,
expressed their interest to actually use the application, thereby indicating that they
were ready to move to the next stage of change.
The mere fact that the people in this study were part of a trial might have biased their
expression of interest. However, the large group of participants that were interested in
the application signals that the free cool sleeve worked well as a trigger to increase
reach for this BCSS. As yet, we were unable to test the effectiveness of the applica-
tion in this study. A more extensive study with a working application should be done
to test whether this application is an effective intervention to support people to actual-
ly change their behavior.
4 General discussion
We have argued that to increase the large potential of BCSS to help people to
adopt healthier lifestyles, the reach of such systems should be enlarged so that the
people that need them most (those who are in early stages of change and are not yet
aware of the need for change) will start using them.
The design case showed that placing triggers in the environment offers possibilities
to connect BCSS to the offline world. In this case, the trigger was a free gift that peo-
ple would receive in a public environment. Although this was not a valuable product,
non-personal triggers may provide solutions that are less costly and can therefore
reach even more people. For such non-personal triggers, a clear and easy to follow
link to a following, more personal intervention is essential.
The case we presented here was about drinking less sugar containing beverages,
however, triggering a behavior change and connecting to BCSS could be effective for
a range of other behaviors that are widespread. One could think of behaviors such as
eating too little fruit and vegetables, unhealthy snacking, etc. What this specific de-
sign case has shown is that analyzing the context of the intervention is important;
what are people’s habits concerning a specific lifestyle issue? What would be the best
place to try to persuade people to try an alternative or to raise awareness of the issue?
We expect that by asking these questions and adding triggers in the environment to
the design of BCSS their reach could be enlarged to include people in early stages of
change. Note that in the design case presented, next to the trigger and the BCSS, a
third product was added aimed at helping to sustain the new behavior. Alternatively,
for this stage of change (maintenance), a BCSS could be adapted to meet the goals for
this stage. Such ‘dynamic interventions’ form an interesting research avenue and
could potentially increase the effectiveness of BCSS to a large extent.
16 Third International Workshop on Behavior Change Support Systems (BCSS 2015)
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