=Paper=
{{Paper
|id=Vol-3153/paper12
|storemode=property
|title=Do Nudges Work? Using Personal Normative Message in mHealth Intervention to Dissuade from Physical Inactivity
|pdfUrl=https://ceur-ws.org/Vol-3153/paper12.pdf
|volume=Vol-3153
|authors=Md Sanaul Haque,Rosa Lanzilotti,Timo Jämsä
|dblpUrl=https://dblp.org/rec/conf/persuasive/HaqueLJ22
}}
==Do Nudges Work? Using Personal Normative Message in mHealth Intervention to Dissuade from Physical Inactivity==
https://ceur-ws.org/Vol-3153/paper12.pdf
Do nudges work? Using personal normative message in
mHealth intervention to dissuade from physical inactivity
Md Sanaul Haque1,2, Rosa Lanzilotti4, Timo Jämsä2,3
1 Dept of Software Engineering, LUT School of Engineering Science, LUT University, Finland
md.haque@lut.fi
2 Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Finland
3 Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland
timo.jamsa@oulu.fi
4 Interaction, Visualisation, Usability & UX Lab (IVU), University of Bari Aldo Moro, Italy
rosa.lanzilotti@uniba.it
Abstract. Physical inactivity leads to a high risk of medical complications and
triggering substantial health care expenses. The goal of the project within which
the research is conducted is to explore the effect of the use of nudges to dissuade
individuals from physical inactivity. This study is aimed to design and develop a
zero/low-cost nudging mHealth intervention that allows users to check their time
with normative messages when walking. This intervention is then utilised for in-
dividuals to investigate whether it stimulates physical activity. The design of the
nudging intervention is followed by an iterative Design Thinking process. The
result of the pilot study has shown us that participants highlighted personal nor-
mative message installed as a screensaver in a smartphone as a zero-cost solution
to dissuade their physical inactivity. Our future effort is to access this intervention
by experimental design studies with quantitative and qualitative surveys, which
will be carried out with students to measure physical activity behavioural change.
Keywords: Nudge, Physical Activity, Design Thinking.
1 Introduction
The United Nations Sustainable Development Goals: goal 3 is intended to “ensure
healthy lives and promote well-being for all at all ages”, and it sets out to end the global
non-communicable diseases by 2030 [1]. Lack of physical activity (PA) is a contrib-
uting cause to a non-communicable disease. Therefore, by 2025, the World Health Or-
ganization member states have set a level to reduce physical inactivity up to 10% [2].
Despite this, some citizens remain constantly physically inactive, thus leading to a high
risk of medical complications and triggering substantial health care expenses
[3][4].Thirteen years after the publication of the Nudge Theory [5], a concept which
Persuasive 2022, Adjunct Proceedings of the 17th International Conference on Persuasive Tech-
nology. Copyright © 2022 for this paper by its authors. Use permitted under Creative Commons
License Attribution 4.0 International (CC BY 4.0)
2
proposes positive reinforcement and indirect recommendations to influence the deci-
sion making and behaviour of individuals, there is now considerable research into
Nudge Theory in many areas. For example, nudging has been applied to improve hand
hygiene among health care employees to decrease the number of health-related infec-
tions [6]. The overall goal of the current project within which the research is conducted
is to explore the effect of the use of nudges to dissuade individuals from physical inac-
tivity. This study is aimed to design and develop a zero/low-cost nudging mobile health
(mHealth) intervention. It includes a wearable touch interactive printed electrochromic
displays (EC) based wrist band or a screen saver on smartphones which allows users to
check their time with normative messages when walking to prolog the walk. This inter-
vention will then be utilised for individuals to investigate whether it stimulates physical
activity. It is aimed to adopt the elements of motivation (hope), elements of simplicity
(time) trigger signals from the Fogg behavioural model (FBM) [7] with a combination
of nudge (personal normative message) to propose a system model for the nudging in-
tervention. Therefore, the following key research question will be investigated:
Is it possible to incorporate a personal normative message in designing nudging inter-
vention to dissuading individuals from physical inactivity?
It is hypothesized that the nudging intervention system to be developed will affect
individuals’ subjective experience by motivating them intrinsically towards physical
activity. To answer the research question, the design thinking iterative process will
guide the design and development of nudging intervention that the user/individual can
use to check the time and be motivated to perform physical activities. The intervention
will be assessed by experimental design studies with quantitative and qualitative sur-
veys. It can be expected that the results of the study will demonstrate a positive impact
to decrease physical inactivity among the users.
2 Nudging
Many attempts at persuasive design fail as users do not understand what factors could
lead to behavior change [7]. Theoretical frameworks are accessible, but these are often
found to be unreachable by practitioners, precisely during design meetings, due to the
fact of being lengthy, complex, and presented in a way that does not support the design
process [8][9]. As a result, designers often fail to understand and take support of be-
havioral theory, as evidenced by reviews that have shown most of the behavior change
mHealth solutions lack theoretical implementation [10].
Peoples’ behaviour can be influenced by cues in the environment which are often
processed outside of conscious awareness [11]. Thaler and Sunstein [5] introduced the
concept of nudging to imply that we can influence our knowledge about cognitive bi-
ases to change behavior in a positive direction. Within the domain of human-computer
interaction (HCI), researchers have enthusiastically implemented the idea of nudging
to foster healthy behaviors [12]. Previous work of nudging interventions in an office
environment showed that it helped to stimulate stair use by employees [13]. Nudges
3
can also be considered cost-effective interventions, which enable individuals to make
decisions that they decide to be their own personal decisions or choices [14]. Normative
messages as a way of nudging have been used to increase healthy behaviours [15], par-
ticularly towards positive anticipated emotion to influence physical activity [16]. Dig-
ital interventions such as mHealth is a possible solution to persuade individuals towards
PA. It has shown to effectively increases PA levels in adults in the short term [17]. In
prior work [18], researchers observed that knowledge on the how of nudging is incom-
plete and highlighted the limited understanding of the long-term effects of nudging in
a technological context and suggested future studies on field trials of digital nudging
interventions to investigate their effects over the long term and once nudges are re-
moved. The present study has been adhered to the above recommendations for thorough
field trials and long-term nudging effects with the mHealth solutions.
3 Methodology
An iterative design thinking process has been utilised to guide the design of the mHealth
intervention. Design thinking is an iterative design process of an application in which
users are involved in every design phase [19]. Design thinking comprises six steps:
empathize, define, ideate, prototype, test, and implementation [20]. Empathizing indi-
cates the sense of ability to share feelings thoughts towards solving problems and chal-
lenges. Define step implies making sense of information gathered from the empathize
step and resulting in a problem statement known as point-of-view (POV). The ideate
step focuses on making ideas and concepts that support designing prototypes, such as
mind mapping, body storming, and sketching. The next step, prototyping, refers to an
early stage of application delivery, for instance, prototyping a nudging mHealth inter-
vention. This prototype can be of any type, i.e., low-fidelity, mid-fidelity, or high-fi-
delity prototype. For examples, a paper object, soft copy or electronic object, or an
interactive display in technology-based solutions. Testing confirms that the prototype
is refined, exploring the users' requirements, and clarifying the POV. The implementa-
tion step ensures that solution is materialized and touches the lives of the end users.
4 Iterative designs and pilot testing of nudging intervention
We performed an ethnographic study, i.e., observed and collected participants’ views
and then moved to the next Define step to draw the conclusions from the Empathize
step and developed an actionable problem statement. The next Ideate step, by which
various ideas was brought to forwarding into Prototyping, testing the prototype, and
implementation of the real working system.
4.1 Empathize
We observed participants’ behaviour, engaged them through interviewing, and watched
and listened to them carefully. Face-to-face interviews were conducted with 13 students
4
at their preferred place (University campus and dormitory lounge). A majority (9/13;
69%) are pursuing their master’s degree at the University of Oulu, Finland. The rest
(4/13; 31%) are from different institutes in Finland studying Finnish language courses
and other part-time courses. Participants were from four nationalities (Finnish, Irish,
Indian, and Bangladeshi, and they are all residing in Oulu, Finland (population,
~200,000). An invitation email was sent out to them to take part in the study. Upon
their consent, we agreed via email and WhatsApp communication with a date and place
for the interview session. The interviews lasted for 15 minutes for each participant and
were conducted between January 15th and January 30th, 2021.
The objective of the interview was to observe participants’ understandings and view-
points concerning their willingness to foster physical activity promotion by utilising the
technology-enhanced solution. The participated students were asked to describe their
experience and views of overcoming physical inactivity in their daily study life, for
example, how they perform PA when sitting for a long-time and their inner thoughts
about anything that could persuade them and any digital tools that might aid them to
conduct the physical activity. All the participated students (13/13, 100%) reported
physical inactivity in their daily life, and most students (12/13, 88%) suggested a tech-
nology-mediated solution to which they can do PA, particularly walking and weight
control. They showed interest to use some sort of motivational message installed or
somehow connected to a technology tool (which we call normative message), e.g., a
wristband or a smartphone in which normative message will appear on the screen dis-
play. The normative message could be something to motivate them daily to prolog their
walks, such as a wise proverb or a famous quotation. They wanted to see the normative
message along with daily clock time in the same digital display, which can attract at-
tention, such as a nudging way to boost up their physical activities. Most of them
(12/13; 88%) recommended a zero/low cost and sustainable technology that might sup-
port them in preventing physical inactivity. Followed by these observations, we have
moved to the Define step to culminate an actionable problem statement.
4.2 Define
The results of the interviews concluded with the following problem statement (POV):
Students sense a lack of being physically active in their daily life. A technology-medi-
ated tool applying normative message can support them overcoming the state of their
physical inactivity and can assist them to self-motivate towards PA such as walking,
running, etc., to increase the net amount of daily movement.
The above POV has drawn our significance attention to how we might build a digital
solution with the aid of the nudging technique. An example was applying the normative
message to which end users can experience more enjoyment and influence in their phys-
ical activity encouragement.
5
4.3 Ideate
The POV from the define step has guided us to design the prototypes of the physical
activity solution. The concept of designing the prototypes was to examine participants’
responses and how they reacted using normative message in line with the nudge tech-
nique using Fogg’s behavioural model (FBG). The prototypes were carefully designed
by adding a normative message. We chose to use this solution because the empathize
step has indicated participants’ interest into applying a personal normative message
with a clock display in it.
4.4 Prototype
The objective of building the prototype was to confirm whether the participants can run
a nudging intervention with a personal normative message and how do they react in
using them. EC are non-light emitting displays and ultra-low power. They have been
the topic of extensive research due to their outstanding potential for application in novel
paper-like display devices, commonly known as e-paper [21]. We chose to use this
because it is a cost-effective solution that can be applied in many application domains,
such as designing mHealth intervention. We designed a wearable touch interactive EC-
based wristband paper prototype that allows users to check their time and a normative
message appears in it (Fig 1).
Fig. 1. Mock-up UI (low-fidelity EC-based and mid-fidelity digital-screen display prototype)
On the other hand, a screen saver on the smartphone is a zero-cost sustainable solu-
tion installed on all mobile devices. It allows users to check their time with normative
messages. Users can wear it in any part of the hand; when they touch a button on dis-
play, time with a normative message appears, such as a wise proverb, “The only push
up you won’t be able to do the one you never do”. This normative message will appear
every time the user presses the turning on the button to operate the smartphone (Fig 1).
Out of these two interventions, one will be selected based on users’ needs and feedback
to conduct the pilot study.
6
4.5 Test
Nineteen students were invited via email/Facebook messenger. Out of those, ten stu-
dents confirmed their availability to participate in the test study. Most of those (8) were
pursuing their master’s degree at the University of Oulu, Finland, and the rest (2) were
from UCC, Ireland and WIT, Ireland. The test was conducted in February 2021. Two
versions of the prototype (EC-based wrist band prototype and a digital display screen-
saver in a smartphone) were provided. The first version of the prototype (EC-based
wrist band) was not interactive, i.e., participants used crafted paper to access the paper
prototype. To test the prototypes, each participant had been allocated 10 minutes for a
single session. They were asked to pretend to use the prototypes as if they were doing
the physical activities in a real-life context (Fig 2).
Fig. 2. The participant is testing prototypes while walking.
All participants reported feeling beneficial after testing the digital display-based
screen saver. They felt that the screensaver option in the smartphone was superior/better
experience than the EC based wrist band. However, five participants highlighted more
than one motivational message, and three other participants mentioned having one mo-
tivational message showing on the display of the intervention. Participants stated as
“Maybe two or three normative messages is enough; seeing one message is monoto-
nous.”,
“If there were random messages, more messages.”
“Every time, different message. For example, 365 messages, every day new message.”
The test result has informed us participants highlighted a zero-cost and sustainable
technology and preferred the personal normative message as a digital display screen-
saver in a smartphone to dissuade their physical inactivity.
7
4.6 Implementation
This is the stage when finally nudging mHealth solution becomes real and is launched
and tested on the real-life scenario. In this study, we have developed a prototype that
users have tested. Once the real working version of the intervention is finalized, it will
be implemented and used by the citizens in real life.
5 Discussions
This study has set up an example of a successful approach in designing a nudge mHealth
intervention using personal normative messages to dissuade from physical inactivity.
However, the study has some limitations, and further research needs to explore several
things. Participants pretended that they used the prototypes, and it was only for 10
minutes. The actual use of the real working mHealth intervention might bring different
users’ experiences. Studies have shown that motivational signage increases physical
activity on study premises [22]. Participants in our study highlighted motivational mes-
sages such as famous quotations or wise proverbs to be installed in the screensaver as
a personal normative message. Researchers [23] demonstrated in a field experimental,
observational study on free tire checks at a gas station that a moral appeal on a sign
placed at a gas station (“Do you care for the environment? Get a free tire check”) re-
sulted in more coupon uptakes for free tire checks when personal pronouns related to
the moral message were used. Hence, linking the moral messages to individuals’ self-
concept will activate an already existing personal norm in the direction of the pro-en-
vironmental behavior [23]. Studies have focused on examining the effect of different
types of personal normative messages and analyzing to what extent several wordings
in such messages may trigger one’s personal norm [24]. Therefore, we could apply this
strategy to activate one’s personal norms, such as students’ persuasion for physical ac-
tivity.
This is a work-in-progress paper. Future studies will focus on a brief description of
how the Fogg behavioural model (FBM) model [7] could be incorporated into the sys-
tem and an additional iteration of the design thinking iterative process. Further ethical
reflection about our research design should be done. In prior work [25] randomized
controlled trial (RCT) based experimental design has been applied in the feasibility
study of physical activity promotion. Once the real nudging intervention will be de-
signed and developed, an RCT-based experimental design will be carried out. Partici-
pants will be randomly selected and divided into two groups (Group A: using a digital
display-based screen saver installed in the smartphones; Group B: continuing their
usual daily routine). The participants' key factors (consisting of intrinsic motivation,
level of influence of the normative messages in the context of their PA behaviour) will
be measured over eight weeks for each condition (experimental and control). These are
subjective measures, and participants' responses (e.g., their daily usage of the interven-
tions to do daily physical activities) will be gathered from participants' responses. On
the quantitative side, psychological need satisfaction in exercise (PNSE) questionnaires
(using the 7-point Likert scale) [26] will be used to measure intrinsic motivation and
8
the level of influence of the normative messages in the context of their PA behaviour.
Face-to-face interviews will be conducted based on questionnaires (which will be for-
mulated and tested based on participants’ feedback and recommendation). Hence, semi-
structured 10-minute interviews [27] will be conducted and audio recorded with partic-
ipants who carry out the study. Thus, the analyses of the collected data will demonstrate
empirically that the nudging intervention positively impacts students’ physical inactiv-
ity. It can be expected that the study results will demonstrate a positive impact to de-
crease physical inactivity among the users.
6 Conclusion
Our study presents the nudging mHealth intervention to motivate individuals for phys-
ical activity promotion implemented in a paper prototype and mid-fidelity touch inter-
active prototype of an app. This study contributes to the HCI community to deepen
understanding of how nudge theory can be integrated to design a zero-cost mHealth
intervention. The study's secondary objective was to develop a prototype of a PA pro-
motion mHealth intervention. We tested the mHealth intervention through a pilot fol-
lowed by the design thinking iteration. Results have shown that participants felt that
using a PA focused mHealth intervention could increase their PA related behaviours
such as walking. The pilot study was small-scale, and due to the paper prototype-based
study, participants could not really draw generalizable conclusions. The limitations of
the study addressed us to examine the intervention empirically, i.e., long-term effects
of it. Our results can guide us to develop a nudging mHealth intervention by adding
extra features, e.g., personal normative message. This study also opens the gateway for
further examination. Further research should concentrate on building actual mHealth
intervention, evaluating in comparison with the existing system, i.e., experimental and
control groups, and working out exactly where the personal normative message plays a
meaningful role. Further research should also focus on users actually using the nudging
mHealth intervention, its usability issues and a long-term study to examine the effect
of the nudging intervention.
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