Modern eHealth technologies, such as serious games, social media and mobile applications addressing health behavior support are evolving rapidly. High-risk young adults with low educational background and of foreign origin could especially benefit from personalized health technologies, designed for their special needs. Sexual health is a delicate subject and well-designed and tailored health technologies are needed to meet the needs of the target group and enhance uptake. The aim of this exploratory user study is to identify the persuasive features and design factors that contribute to the use and uptake of existing and new health technologies. Four focus groups were conducted with 37 young adults to gain insights into their needs and attitudes, with sexual health case used in the study. Qualitative data analysis was performed based on Persuasive Design model to identify stimulating, blocking and neutral persuasive features, specific for high-risk young adults, as well as generic design factors. Five generic design factors are formulated based on our findings: (1) anonymity, (2) interactivity, (3) portability (4) source and (5) comprehensibility. These findings aim at informing the design of health technologies for lifestyle and sexual health behavior change support of high-risk young adults, and could be applicable for young adults in general and other health topics.
Young adults, especially young adults who are poorly educated, are at higher risk for
leading an unhealthy lifestyle on different aspects that have an effect on health
behavior, including nutrition, physical activity and sexual health. Among other health
topics, there is growing importance of addressing the sexual and reproductive health
needs of adolescents (10-19 years) and young people (10-24 years) [
In the context of sexual health, ‘classic’ face-to-face consultations are poorly
known among vulnerable young adults [
Efforts within public health and epidemiology research directed towards reaching
young adults of foreign origin in the context of sexual health are limited to
informative websites and community-based approaches [
With the emerging new technologies, such as serious games, social media and
mHealth, new opportunities arise for persuasive and personalized health to support
behavior change [
Previous research on the design of persuasive health technologies involving
highrisk young adults is lacking. Young adults of foreign origin are a hard to reach target
group. There is also little known about their needs for the design of health
applications [
In this study, we investigate how technologies for health behavior support of
vulnerable young adults should be designed to meet their needs. This paper presents the
results of the exploratory focus groups study on the specific user requirements and
conditions for the design and implementation of health technologies for behavior
change support of young adults. The primary focus in this study is on social media
[
In total, four focus groups were conducted with 37 young adults (51, % male and 48,6% female) with low socio-economical status and from various ethnical backgrounds with average age between 12 and 24 years (M=17.4, SD=3.1). The birth country of the mother or father determined their ethnic background, where the country of the mother was leading when both parents are from foreign decent. Participants’ ethnicity was related to a variety of geographical regions: Turkey, Surinam, Morocco, The Netherlands Antilles, Iraq, and Afghanistan. Sixty percent of the participants were from the first four regions, which represent the four biggest immigrant groups in the Netherlands. Participants were recruited via the municipal health services and the social workers at the local youth centers in three different cities and regions across the Netherlands. All participants signed a consent form prior to the study. Additional consent from parents was collected for participants younger than 16 years. Participants received a cinema gift voucher of €15, goodies (ballpoints and condoms), and refreshments as an incentive. Groups were composed of all male or all female participants to ensure comfort discussing sexually related topics. 2.2
The focus groups were held at the local youth community centers as a follow-up of the educational weekly activities organized by the social workers, and lasted between 70 to 75 minutes. Trained moderator and an assistant led the focus groups. The moderators used a discussion guide, during the focus groups important points from the guide were also presented to participants in a PowerPoint presentation. The assistant took notes and answered questions during the subgroups activities. The final version of the guide was developed based on a pilot test group and was used for all four focus groups. Questions were posed in an open-ended manner followed by more specific prompts.
The focus groups discussions were divided into five components. First, moderator gave a short introduction, explaining the purpose of the focus group and the role of the participants. To promote confidentiality, participants were given a choice to use either a first name or an imaginary nickname for the name boards to address each other during the discussion. Participants were asked to fill in a questionnaire on demographics such as age, gender, level of education, ethnical origin of parents and how open the young adults feel about discussing health topics such as sexual health. In the second component, the participants were split in two subgroups (4 - 6 participants per group) to explore two different application types: serious online game ‘Can You Fix It?’ and mobile application ‘Dance4Life’ providing information on sexuality and sexual health (see Fig. 1 and Fig. 2). After a free exploration, each subgroup was asked to discuss the usefulness and suitability of the application for them, positive and negative experiences and suggestions for improvement. In the third component, a plenary discussion on opinions and experiences of young adults followed in subgroups.
Next, in the fourth component, the moderator showed and discussed an example of
a social media application: a Facebook (FB) page of the regional municipal health
services and a YouTube movie on how STI test is done. In the fifth part, examples of
possible new applications for health behavior support were discussed. These
concerned two concepts: a serious game via Facebook and a Virtual Coach [
Focus group sessions were audio recorded with a digital voice recorder with
participants’ permission. During the data analysis, audio files were transcribed verbatim,
analyzed, coded and categorized. An analysis of the influence of various persuasive
features on the response of young adults towards various types of health technology
was done (Braun 2006). Persuasive features were coded according to the Persuasive
System Design model [
“The information has to be reliable.” (Coach) Real-world feel with quotes. motivating the user. Table 2 illustrates the identified blocking persuasive features Neutral features. Neutral features are the ones perceived as having no effect on motivating the user, perceived usefulness and/or adherence. Table 1 illustrates the identified neutral persuasive features with quotes.
Quote
Quote “People who don’t go outside often can play this and learn how it is in the outside world.” (Game) “The fact that I could win condoms would not influence me” (FB page) Expertise
“I want it to be made by someone who has the Five general design factors were formulated based on the analysis of the focus group data and the identified persuasive features presented above, namely: (1) anonymity, which has implications for the use of social networks, (2) interactivity, as it facilitates engagement and ensures better uptake of interventions; (3) portability of the technologies, as it ensures privacy and effortless use; (4) source of the information within the application has to be visible and reliable to be perceived as trustworthy and (5) comprehensibility, meaning more visually aided and easily worded information.
These generic factors aim at informing the design of health technologies for lifestyle and sexual health behavior support of young adults. Incorporating these factors and persuasive features into the design of health technologies for young adults for behavior change support should increase their usefulness and uptake by the target group. Each factor is described below with relevant quotes from the participants. Anonymity. The participants all agreed that anonymity is a crucial factor for health support: ‘If you look it up on a computer your parents can see it on your screen.’ (Mobile app); ‘I would go to a friend to use the Internet. Otherwise your mom can come inside or something...’ (Serious game).
Besides the perceived risk of ‘being caught in the act’, online and mobile applications sometimes also register visit, a feature that was not appreciated by young adults of foreign origin. They are not inclined to look for information on sexual health via social networks such as Facebook or Twitter, as their friends and family can see their activity right away: ‘I think it is inappropriate that my family can see that I visit this page.’ (FB page); ‘If you ‘like’ something, friends know right away what you are doing!’ (FB page). Thus, this factor has important implications for the use of social networks for sexual health promotion.
Interactivity. Participants often mentioned interactivity as a missing feature or a feature that is not fully available. For instance, after playing with a serious game during the focus group discussion participants stated that they would have liked to intervene more often during the game than it was actually possible. This is illustrated in the following reaction expressing frustration: “I find it strange that I couldn’t click that often, because I wanted to ‘Fix’ more often but that was not possible!” (Serious game).
It is not just the presence of interactivity that is important, but the level of the interactivity seems to be crucial in order to facilitate better engagement. For instance, in the serious game interactivity was incorporated, but could have been expanded further. The mobile application, on the other hand, only allowed navigating through various menu items at all times and yet participants missed an interactivity feature allowing to contact a sexual health care professional: ‘I also want to be able to ask questions myself, and get an answers.’ (Mobile app).
Interactivity seems to have a positive effect on the perceived usefulness of the health technology which could especially contribute to a richer and better user experience.
Portability. Portability of the platform on which the health technology is realized plays a crucial role for young adults. Participants had a clear preference for a mobilebased type of platform, as opposed to the web-based platform as it insures privacy and effortless use for this specific target group: ‘You always have your mobile phone with you. It is faster.’ Another participant mentioned: ‘If you just search for these things (information on sexual health) on the internet, … you get everything (on your desktop), with a mobile app it’s easier.’
Young adults would rather use the search functions directly on their mobile phone, without a link with social networks: ‘If you really need this (search function) you just download it (on your mobile phone) and you know that it is not visible anywhere else.’ (FB page). Participants also preferred to be able to use certain location features of the mobile application offline: ‘I want to look up things online but also offline, without WIFI for instance, like these things nearby (location of the free consultation).’ (Mobile app). In the last quote, the participant refers to a location tracking service on a mobile application that allows a user to find an office of a nearest free sexual health consultation by typing a zip code.
Source. The participants mentioned that the source of the information, independent of the type of platform, is also important for them to be able to evaluate the quality of the information. The source of information has to be explicitly stated, clearly visible and trustworthy: ‘It looks attractive, but you want to know what (source) is behind it.’ (Serious game); ‘I want it to be made by someone who has experience with it…’(Personal coach); ‘There should not be a name (of the public health care provider), but a logo or something.’ (FB page).
Participants indicated that they would trust the provided health information more when it is clearly stated that the familiar public health organization, such as Municipal Health Services is behind it: ‘…If you know it’s (information on a page) is from the Municipal Health Services, then yes. Then the people will be willing to use it...’ (Facebook). And another participant said: ‘The Municipal Health Services are famous (familiar), that is good.’ (Facebook).
Comprehensibility. Comprehensibility of the health technologies is another important factor, which was divided by two sub-themes specific for young adults with foreign origin: visually aided information and availability of applications in different languages. Overall, the participants appreciated the visual aesthetic of the applications: ‘Mostly you would play (use) it more if it looks attractive.’ (General). Several participants described the importance of visually aided information: ‘There are so many pictures here, I like that.’ (FB page). Other participants mentioned that not only the design with images was important, but also the colors of those images: ‘I would play it if there is a nice image, with different colors’ (Serious game).
Another sub-theme that emerged was the language used in the applications. One of key characteristic of young adults of foreign origin is that they often speak different languages with their families at home. The availability of the applications for lifestyle and health behavior support in other languages (than Dutch) would benefit their use: ‘I also want to have an English version of the app.’ (Mobile app). To conclude, persuasive health technology for lifestyle support and health behavior change have to be more visually aided and easily worded, if possible in different languages and the vocabulary of the low-educated young adults as a specific target group.
Next, we discuss the findings and implications for the design and implementation of persuasive health technologies and online interventions for behavior change support. 4
This study employed focus groups to get insights into persuasive features and design
factors that influence the use and adoption of various forms of modern health
technologies for lifestyle and behavior change support among vulnerable young adults,
such as low-educated young adults and young adults of foreign origin. Even though
this study primarily focused on the sexual health behavior, identified persuasive
features and design factors might also be applicable for other lifestyle and health topics
like physical activity support [
Sexual health is a delicate and sensitive subject independent from ethnic
background, however we believe that having a certain ethnical background can increase
the sensitivity of this information, for instance due to stigma. This point is also
confirmed by the other recent studies, suggesting that stigma around sexual health could
affect the use of social media among young adults [
Our findings show that even though persuasive health technologies offer unique
opportunities for young adults of foreign origin, designers have to take into account
the specific needs of this group. Our results indicate that anonymity is an important
factor, which has major implications for the use of online technology for enhancement
of sexual health. This is especially an issue for the social networking websites, such
as Facebook, as these media are meant to share information with peers. Despite the
expectations from other research on the important role of social support features for
young adults [
Additionally, the participants in our focus groups highly appreciated interactivity.
The presence of interactivity was experienced is less important. The level of the
interactivity, on the other hand, seems to be a crucial factor in order to facilitate better
engagement. Higher interactivity can be also associated with more challenging and
engaging user experience. Rich engaging interaction imbedded in the interfaces of
social media applications, mobile apps and serious games may contribute to a better
uptake of the intervention, as identified in another study with young adults [
Portability was another important factor, as it insures both privacy and effortless
use wherever participants are [
Furthermore, independent of what kind of technology is offered, the source of
information has to be visible and to be perceived as trustworthy. Trust to the provided
source of information can be identified by the recognition and familiarity with the
logo of the health organization. Recent research also identifies trustworthiness of the
information as a crucial factor for the successful application of the modern technology
in sexual health care for young adults [
The design factors we mention above could apply to adults of foreign origin, as well as young adults in general. The fifth factor, which is especially connected to young adults of foreign origin, is the comprehensibility of the information offered by persuasive health technologies. Specifically, health technologies for behavior change support have to be more visually aided and easily worded, possibly in different languages and the vocabulary of the low-educated target group. Although this seems an obvious conclusion, many public health interventions have not been properly evaluated in cooperation with the specific target groups, such as adults of foreign origin before and after going ‘live’. Furthermore, it is essential to involve the target user group in the design of persuasive health technologies for behavior change support.
Additionally, one of the participants said that it would be good if the health
applications were designed separately for men and women, or at least tailored towards the
specific needs of both genders. Additionally, it seemed that men and women found
different design esthetically attractive. Gender specificity did not emerge as a factor,
but does give some insights into the reason why existing health interventions might
mostly reach women [
In our study, we focused on identifying the persuasive features and design factors
for health behavior change support through persuasive technologies, to meet the
specific needs of vulnerable young adults. There is, however, another factor that can be
attributed to the success of applications for sexual health support, namely the reach of
these applications. The design maybe perfectly tailored towards young adults, but if
they do not find and use these applications the effort to improve them is moot. The
current practice is to create more demand by more supply. Moreover, there are many
online interventions available to promote sexual health in the hopes of reaching their
target groups. It remains a challenge to guide the users towards the ‘reliable’
applications. Trustworthiness of the source and one central platform that combines several
high quality health interventions are needed [
Our research on sexual health does not include sexual health in all it facets. We
have focused on sexual health as in the absence of infections and information about
infections. However, sexual health also entails sexual pleasure and the ability to enjoy
your sex life [
Focus groups are an ideal method to investigate a delicate and sensitive subject as sexual health. On the one hand, focus groups are usually kept small, to facilitate participation and profound discussions. On the other hand, keeping the focus groups small also induces some limitations. They can only yield qualitative data. Not all adults of foreign origin that can be found in the Netherlands were part of the current focus groups. However, the four largest immigrant groups were well represented in our study. Furthermore, the various ethnic backgrounds were mixed in the focus groups, possibly making it difficult to express some culturally specific opinions.
The second limitation of our study is that foreign origin and low education are confounded in our study. The young adults who participated also had low educational background. Therefore, it is possible that the factors that emerged were contributable to level of education instead of ethnic background. This is a potential bias, but also a strength, as it gives more insight into the special needs of the vulnerable target group who could potentially benefit from persuasive technologies for sexual health behavior support most. Finally, one focus group had a different moderator but was assisted by the same assistant for taking notes. Both moderators used the same instructions and discussion guide and the audio recordings of all focus groups were transcribed and analyzed by the same investigator using the same coding scheme, as well as crosschecked by the second investigator to avoid bias.
The current results can contribute to future developments of persuasive health
technologies, specifically aimed at enhancing healthy lifestyles and health behavior of
high-risk young adults. We suggest, for instance, a mobile application as a type of
platform, that would optimally assist anonymity and would be accessible from
anywhere [
In conclusion, several stimulating, blocking and neutral persuasive features specific for high-risk young adults were identified in this exploratory study, as well as five generic design factors. Namely, health technologies for young adults should be anonymous, interactive, portable, from a reliable source, and easily comprehensible for the user. These findings aim at informing the design of health technologies for lifestyle and sexual health behavior change support of high-risk young adults, and could be applicable for young adults in general. Incorporating these factors and persuasive features into the design of health technologies for behavior change support, for sexual health and also over health topics, suggest to increase their usefulness and uptake by the target group. As part of the future work, we are currently designing the new personalized health application for self-management support of high-risk young adults, incorporating the identified persuasive features and design factors and involving the potential users and sexual healthcare professionals in the holistic iterative design approach.
Involvement of the target group throughout the whole development process is
crucial, as well as iterative evaluation of the design with them to increase uptake and
ensure successful implementation and ultimately better sexual health. Moreover,
future research should also focus on the specific evaluation methods to measure the
effects of persuasive technologies on the health behavior and lifestyle of young adults.
This important topic is highlighted in detail in other studies [
Acknowledgments. We would like to thank all participants of the study and social workers of the youth centers. Special thanks are due to Irina Lehmann for assistance in recruitment and data analysis. Focus group study was carried within a master graduation project. This work was supported by the Dutch Ministry of Health, Welfare and Sport (VWS) under grant 2012/2 and is carried out in collaboration with the Dutch National Institute for Public Health and Environment (RIVM).