Opportunities and Challenges of Behavior Change Support Systems for Enhancing Habit Formation: A Qualitative Study

Abstract Theformationofhealthyhabitsisconsideredtoplayafundamentalrolein

healthbehaviorchange.AvarietyofstudiesonHealthBehaviorChangeSupport

Systems(HBCSS)havebeenconductedrecently,inwhichindividualsusesuch

systemstoinfluencetheirownattitudesorbehaviorstoachievetheirpersonal

goals.However,comparativelymuchlessresearchhasbeendevotedtostudying

howtheusersofthesesystemsformhabitswiththehelpofHBCSS,orto

understandinghowtodesignthesesystemstosupporthabitformation.

Objective:TheobjectiveofthisarticleistostudyHBCSSuserexperiences

regardinghabitformationthroughaninterventionstudytargetedatestablishing

ahealthierlifestyle.Thisstudyalsoaimstomaphabitformationstages,as

suggestedbyLallyandGardner,withthePersuasiveSystemDesign(PSD)model.

Theapplicationdomainisthepreventionofmetabolicsyndrome,inwhich5%

weightlosscansignificantlyreducetheprevalenceofthesyndrome.

Methods:Thisstudyemploysaweb-basedHBCSSnamedOnnikka,alifestyle

interventiondesignedforthepreventionofmetabolicsyndromeforparticipants

whoareatriskofdevelopingametabolicsyndromeorarealreadysufferingfrom

it.Thesystemunderinvestigationwasdesignedaccordingtotheprinciplesof

thePSDmodelandBehaviorChangeSupportSystemframework.Lallyand

Gardner’sresearchonthestagesofhabitformationwereusedtostudythe

extenttowhichtheOnnikkasystemwasabletoenhancethedevelopmentofnew

habits.Atotalof43Onnikkauserswereinterviewedforthisstudyduringand

aftera52-weekinterventionperiod.Theresearchapproachemployedherewas

hermeneutics,whichleansontologicallytowardthesocialconstructionofreality,

gainedthroughlanguage,consciousness,andsharedmeaning.Inaddition,the

system’slogindataandparticipants’weightmeasurementswereutilizedtobuild

aninterpretationoftheresults.

Results:ThefindingsofthisstudysuggestthatIThabitsappeartohaveastrong

linkagewithuseadherence,whereaslifestylehabitsdidnotseemtobedirectly

relatedtothe5%weightlossamongstudyparticipants.Moreover,habit

formationstagesprovideapossibleexplanationforwhyself-monitoring,

reminders,andtunnelingwereperceivedasespeciallyvaluablefeaturesinthis

study.

Conclusions:Forsustainableweightmanagement,holistice-health

interventionsarerequired,andthePSDmodeloffersapracticalapproachfor

designinganddevelopingthem.Recognizingthestagesofhabitformation

providesadditionalvaluableguidancefordesigningsystemsthathelpshapean

individual’shabits.

Keywords:BehaviorChangeSupportSystems;e-health;PersuasiveSystems

Design;Habitformation;IThabit;Interpretiveresearch.1

1 Introduction Obesityisagrowinghealthproblemworldwide,andisassociatedwith

numerouscomorbidhealthconditions[1].Themeanbodymassindex(BMI)as

wellasoverweighthaveincreasedgloballysince1980,andmostcountriesarein

needofnewpoliciesandinterventionsinthisregard[2,3].IntheUnitedStates,

themostcommonweight-lossstrategiesincludearestrictednumberofcalories,

areducedamountoffat,andanincreasedamountofexercise,whichapplyto

approximately50%ofweightlosers[4].Maintainingweightlossischallenging

[5],asachangeinphysicalactivityordietisnormallyinsufficienttomaintain

weightloss;amorecompletechangeinlifestyleappearstobenecessaryforthis

purpose[6].However,evenmoderateweightlosscansignificantlyreducethe

riskofhealthproblemslikecardiovasculardisease,andwitha5%reductionin

bodyweightthereisasignificantimprovementinglycemiccontrolfordiabetics

[7,8,9].

Severalstudieshavepresentedthepotentialofwebinformationsystems

supportingweightlossandweightmanagement[10,11,12,13,14].Accordingto

1Abbreviations:HBCSS:HealthBehaviorChangeSupportSystem;e-health:Deliveryofhealthservicesviaremotetelecommunications.Inthiscase,awebinformationsystem;PSDmodel:PersuasiveSystemsDesignmodel.

theInternationalTelecommunicationUnion’sstatistics[15],in2017,Internet

penetrationwasalreadyat48%oftheworld’spopulation.However,web-based

interventionsstillhaveonlyarelativelysmalleffectonhealthbehaviorona

globalscale[14],e.g.inKaipainenetal.’s[16]study,only25%ofindividualswho

registeredtotheinterventionwebsitereturnedtothefollow-upsurveys,and

thereforetheeffectoftheirinterventionispossiblyoverestimated.Overadecade

ago,Eysenbach[17]arguedthatthegreatestchallengewhendeveloping

comprehensivesystemsforhealthinformaticsisthesparseamountof

knowledgeregardinghowindividualsuse,process,andinteractwithhealth

information.Eventoday,Eysenbach’sclaimsappeartobevalid.

Brouweretal.[18]presentedhowalargevarietyofbehaviorchangetechniques

andstrategiesarebeingusedforvariouslifestylebehaviors.Oinas-Kukkonen

[19]maintainedthatdespiteusingbehavioraltheoriesindevelopinghealth

interventions,thesystemitselfisoftendescribedsopoorlythatitcanevenbe

consideredablackbox.Heproposedarelatedconcept,knownasBehavior

ChangeSupportSystems(BCSSs),highlighting“autogenousandvoluntary

approachesinwhichpeopleuseinformationtechnologiestochangetheirown

attitudesorbehaviorsthroughbuildingupontheirownmotivationorgoal.”[19,p.

1227].Agreatnumberofweightlossandweightmanagementapplicationshave

beenintroduced,bothinresearchandinpractice,butresearchreportingonuser

experiences,actualoutcomes,andhowthesetworelatetoeachothercontinues

tobescarce.Moreover,inmostcases,thesoftwarefeaturesofsuchapplications,

includingtheirpersuasivefeatures,havenotbeenthoroughlyreported.

Nevertheless,persuasivedesignisimportant,sinceithasbeenshowntoaffect

theadoptionofHBCSSs[20]andadherencetoit[21].AccordingtoSharpeetal.

[22],lackofuserengagementhindersthefullpotentialofdigitalweight

managementinterventions.

Theremainderofthearticleisstructuredinthefollowingmanner.Thesecond

sectiondescribesthemainideaunderlyingthePersuasiveSystemsDesign(PSD)

modelbyOinas-KukkonenandHarjumaa[23].Thethirdsectionconcentrateson

theactualweb-basedinterventionthatwascreatedfortheresearchproject

addressedinthisarticle.Thereafter,themethodologyusedinthisstudyandthe

habitstagesintroducedbyLallyandGardner[24]arediscussed.Themain

sectionsthenpresenttheresultsofthestudyathandandtheimplicationsof

theseresultsforbothresearchandpractice.

2 Persuasive Systems Design ModelOinas-Kukkonen[19]hasintroducedmultipletheoreticalframeworksthatcan

bedirectlyutilizedforconductingresearchontechnologicalbehavioralchange

interventions,andheprovidesreferencesto14distinctbehaviorchangerelated

modelsortheories.Inhisvision,thedesignofHBCSSsneedstoaddress

technologicalissues,thequalityofinformation,personalgoal-setting,andsocial

environments;HBCSSsoftenmustbealwaysavailableandtakeintoaccount

globalandculturalissueswithamultitudeofbeliefsandhabits;HBCSSdonot

merelycollectandtransforminformation,butsupporttheiruserstochangetheir

behaviorforthebetter;HBCSSaimtoinfluencetheirusersandthereforethey

arefundamentallypersuasive.Bydefinition,HBCSSdonotusedeceptionor

coerciontopersuadeitsusers[19].

ThePersuasiveSystemsDesign(PSD)modelintroducedbyOinas-Kukkonenand

Harjumaa[23]isoneofthecenterpiecesinthisresearchareaandhasbeenused

vastlyintheresearch[25,26,27,28].ThePSDmodel[23]suggests(1)asetof

sevenpostulatesregardingpersuasivesystems,(2)analysisoftheintent,event,

andstrategyofpersuasion,and(3)definespotentialsystemfeaturesforBCSSs:

(1) Oinas-Kukkonen[19]underlinesthatbeforeconsideringpersuasive

featuresoranalyzingthecontext,thedesignershouldobtainadeeper

understandingofpersuasiononapostulatelevel.Thesepostulatesare

notdetailedinstructions,rathertheyshouldbethoughtofasthemain

statementsofsystemdesign.Forexample,thepostulate“Persuasive

systemsshouldaimatbeingbothusefulandeasytouse”hasitsfoundation

onthedeterminantsoftheTechnologyAcceptanceModel(TAM)byDavis

[29].Ifasystemisdifficulttouseandisnotperceivedasuseful,itis

probablynotgoingtobepersuasiveeither.ThreeofthePSDmodel

postulatesarebasedonfindingsinpsychology.Forexample,thepostulate

“Directandindirectroutesarekeypersuasionstrategies”derivesfrom

PettyandCacioppo’s[30]ElaborationLikelihoodModel(ELM).The

postulatearguesthatauserwhocarefullyevaluatesthecontentofthe

persuasivemessagecanbeapproachedbythedirectroute,butauser

whoislessthoughtfulmaybepersuadedthroughtheindirectroute,

wheresimplecuesorstereotypescanbeuseful[23].

(2) ThenextelementinthePSDmodelistheanalysisofthepersuasion

context,whichconsistsofidentifyingtheintentofthepersuasion,

recognizingthepersuasionevent,anddecidingthepersuasionstrategy

[23].Inthisphase,adesignerneedstotakeintoaccountaspectslikeuser-

dependentfeatures,suchastheuser’sgoals,motivation,lifestyle,etc.

Further,sincenewtechnologieshavebecomeavailableatanincreasing

pace,therisksandopportunitiesneedtobeevaluatedthoroughly[19].

Theusecontextitselfholdsdomain-dependentfeatures.Inthehealth

domain,thisusuallyinvolveshealthcareprofessionalsinthedesign

processandcreatingcontentforthesystem.

(3) ThethirdmainelementinthePSDmodelarethe28designprinciples,

whicharedividedintofourcategories:theprimarytasksupport,

dialoguesupport,systemcredibilitysupport,andsocialsupport[23].The

primarytasksupportcategorycomprisespersuasivefeaturesthataim

toreflectusers’behaviorgoalsandtracktheirprogresstowardthem.For

example,empiricalstudieshavefoundself-monitoringtobeprominentin

changingphysicalactivityandeatingbehaviors[22,31].Thiscategory

alsoincludesessentialissues,suchasdisorientationinsystemuseand

reducingtheindividual’scognitiveload.Further,thetunnelingfeature

guidesusersthroughthechangeprocessandfocusesonthesequencein

whichtheinformationispresented.Thepersuasivefeaturesinthe

dialoguesupportcategoryarerelatedtouserfeedbackandhuman–

computerinteraction.Theseprinciplesaimtokeeptheuseractiveand

motivatedduringthesystem’suse.Severalarticleshaveillustratedthe

valueofremindersinincreasingtheeffectivenessofweb-basedhealth

interventions[14,21,32,33].Thecredibilitysupportcategoryhelpsto

creategreatercredibilityinthedesignand,thus,amorepersuasive

system.Anindividualshouldbeabletotrustthesystem,acceptitsadvice,

andbelievethattheywillbeguidedtothetargetedgoal[23].Thesocial

supportcategorymotivatesindividualsbyleveragingsocialinfluence.

Technologycansupporttheformationandmaintenanceofonline

relationships,whichinturncanfacilitatesocialsupport[34].

2.1 Case Onnikka: Web-based Health BCSS

ThecurrentstudyemploysaHBCSS,knownasOnnikka,whichwasdesignedin

thePreventionofMetabolicSyndrome(PrevMetSyn)lifestyleintervention

researchprojectforparticipantswhoareatriskofdevelopingametabolic

syndromeoralreadysufferingfromone.ThesystemwasdesignedattheOulu

Universityjointlybyresearchersofinternalmedicine,informationsystems,and

informatics,followingthedesignprinciplesofthePSDmodel[23]andBCSS

framework[19].Theoriginalarchitectureofthesystemhasbeendescribedin

Alahäiväläetal.[35]2.

Onnikkaisawebinformationsystemthatuserscanaccesswiththeirpersonal

credentialsforadurationofoneyear.Thetechnologicalimplementationof

Onnikkawasconductedusingtechnologiesthatuserscouldaccesswiththeir

desktopdevicesormobilephones.Throughoutthe52-weekinterventionperiod,

usersreceivedweeklyhealtharticlesandtasksrelatedtothetopic.The

informationcontentfollowedthecognitive-behavioralapproach[38].Theaim

wastosupportparticipantstocopewithdysfunctionalthoughtsthatwould

likelyinterferewiththeirbehavioralgoalsandtohelptheirself-efficacy

regardingweightmonitoring,eating,exercise,andweightloss.

ThefollowingkeypersuasivefeatureswereimplementedintheOnnikkasystem:Primarytasksupport:ThecoreprimarytaskfeatureoftheOnnikkasystem

wasself-monitoring.Participantscouldsubmitentriesregardingtheirweight,

2Researchfindingsrelatedtouserflowexperience[36]andusers’perceptionsregardingdifferentpersuasivefeatures[37]havebeenpublishedpreviouslyinthePrevMetSynresearchproject.

exercise,mood,andeatinghabits.Theymappedtheirweightchangesintabular

formorasagraph.Further,theycouldwritediaryentrieswith“smileys”to

expresstheiremotionsduringeveryinterventionweek.Theycouldalsomonitor

theirexercisebysubmittingentriesinwhichtheydescribedthetypeofexercise,

theamountofexercisedone,andthelevelofstrain.Participantscouldalsoadd

informationtoafooddiary,whichincludedentriesregardingthemealtype,

description,theeatingtime,andtheplace.Additionally,participantscouldreflect

theireatinghabitsbymarkingthemealas“unnecessary”or“proper”.The

contentofthesitefollowedthepersuasivefeatureofreduction.Onnikka

simplifiedacomplexbehaviorintoseparatethemes(nutrition,exercise,etc.),

therebyguidingparticipantstotargettheirbehaviorchangeactivitiestothe

mostrelevanttopics.Acloselyrelatedfeaturetoreductionistunneling,a

predeterminedsequenceofinformationprovide,whichdoesnotallowauserto

deviatefromthepathwhiletheuserisinatunnel.Hereitwasimplementedas

anunchangeablerhythmofprovidingweeklyinformationcontentandtasksin

whichsomeofusers’navigationaloptionswerenotmadeavailableatalltimes.

Participantscouldbrowsebackovertheirpreviousentries;however,new

contentwasnotaccessibleinadvance.Accordingtocognitive-behavioral

approach,individualneedstoprocessthechangeactively,whichrequires

sufficienttime.Inaddition,itwasnecessarytokeepthetimingofHBCSSsimilar

toallparticipants,sothattheinterventionwouldnotbetoodifferentforeach

individual.Moreover,participantscouldsubmittheirtaskanswerstothesystem.

Additionalcontentwastailoredtobevisibleonlytocertainindividualsbasedon

theirbehavioralprofiles,whowereinneedofcounselingoneatingbehavior.

ThisfeaturefollowstheprincipleoftailoringinthePSDmodel.Eatinghehavior

wasevaluatedusingtheThreeFactorEatingQuestionnaire(TFEQ-18,Karlsson

etal.[39]).Itassessesthreedimensionsofeatingbehavior:cognitiverestraint

(CR),uncontrolledeating(UE)andemotionaleating(EE).InTFEQ-18theresults

arecalculatedasapercentageofthehighestpossiblevalueanditisbetween0-

100%.Ifthescoreforuncontrolledeating(UE)oremotionaleating(EE)wasin

thehighesttertile,theparticipantwascategorizedasa“participantwith

problemsofeatingcontrol.”Thestudyparticipantswithhighestscoreswere

evenlyrandomizedinallcounsellinggroups.ThecontentoftailoredOnnikka

includedextraexercisesofrecognizinganddealingwithemotionsorrisk

situationsforeating.

Computer-humandialoguesupport:Followingtherecommendationsofthe

praisefeatureinthedialoguesupportcategory,persuasivemessageswere

conveyedintheweightsubmissionprocess.Followingthepersuasionprinciple

ofreminders,Onnikkasentweeklye-mailmessagestousersonMondays,andif

theyhadnotyetloggedintothesystemduringtheweek,anothermessagewas

sentonThursdays.Further,Onnikkasentweeklytipsforgoodeatingbehaviorto

thetailoredusergroup,followingtheprincipleofsuggestion.Thesystem’svisual

appearance,usingphotographsoflocalenvironmentsandpeoplewereselected

basedonthepersuasiveprincipleofliking.

Credibilitysupport:Thesystemprovidedexternallinks,fromwhichusers

couldverifyinformationandgainextraknowledge.Otherthanthis,the

persuasionprinciplesinthecredibilitysupportcategorywerepaidsomewhat

lessattentionto,astheparticipantswereratherfamiliarwiththeauthorities

behindthesystem(universityandhospitaldistricts).

Socialsupport:Socialsupportwasimplementedinthesystemasadiscussion

columnattachedtoeachweeklyhealthcontentfollowingtheprincipleofsocial

learning.Userscouldusepseudonymstoanonymouslysharetheirthoughts.The

homepageindicatedthetotalnumberofloggedparticipantsforthatintervention

week,whichfollowsthesocialfacilitationpersuasionfeature.

Primarytasksupport Dialoguesupport Socialsupport CredibilitysupportSelf-monitoring:Weightgraph,Fooddiary,Exercisediary,Mooddiary

Reminders:Weeklye-mailstologintothesystem,followedbyanotherremindertologiniftheuserhadnotloggedinbyThursday

Sociallearning:Discussionforum

Verifiability:Linkstoexternalsources

Reduction:Weeklycontentonseparatethemes

Praise:Encouragingtextualfeedbackaftersuccessfulweight-lossperformance

Socialfacilitation:Numberofloggedusersforthecurrentinterventionweekandthenumberofcommentsgivenshownonthefrontpage

Tunneling: Suggestions:

Unchangeablerhythmofweeklycontent,exercises,andtips

Tipsforgoodeatingbehaviorssenttothetailoredgroup

Tailoring:Additionale-mailmessages,informationcontent,andtailoredexercisesforthoseinneedofadviceoneatingbehavior

Liking:Visualappearanceofamodernwebapplication,usingphotographsoflocalenvironmentsandpeopleinthecontent

Table1.Persuasivefeaturesaddressedinthisstudy,followingtheguidelinesofOinas-Kukkonen[19]andOinas-KukkonenandHarjumaa[23].

3 Research Context and Data Collection PrevMetSynisarandomizedlifestyleinterventionstudy.Thestudyparticipants

wereFinnishcitizensfromtheNorthernOstrobothniahospitaldistrictarea.Both

maleandfemaleparticipantswereofworking-ageandwereeitherobeseor

overweight(BMI27–35).Allstudyparticipantsprovidedawritteninformed

consent.ThestudyhasbeenapprovedbytheEthicsCommitteeofthehospital

districtofNorthernOstrobothnia,Oulu,Finland(decisionnumber29/2012).The

studywasregisteredinClinicalTrials.govwiththeidentifierNCT01959763.

Atotalof532voluntaryparticipantswerescreenedandrandomizedto6groups:

groupcounselling(8times,2timesornone)withorwithoutthe52-weekHBCSS

support(usersofOnnikka).Thisstudyconcentratesonthe259usersofOnnikka,

whoweredividedintofivedifferentstartinggroupsbetweenMarch2013and

March2014forpracticalpurposes.Onnikkawasnotlinkedwithanyface-to-face

counselinganddidnotuseassistancefromhealthprofessionals.

Thequalitativedataforthisstudywascollectedfromthreesemi-structured

interviewcycles.ThefirstdatacollectioncyclewasmadebetweenJune5and7,

2013,when12individualsparticipatedintheinterviewsduringintervention

week12.Thesecondsetofinterviewswasconductedwithanother12

participantsbetweenNovember6and21,2013.Atthetimeoftheinterviews,

theseparticipantswereininterventionweeks25–27.Thethirdinterviewcycle

wasconductedbetweenSeptember22andOctober21,2014;thisgroup

contained20participants—4individualsfromeachofthe5differentstarting

groups.Inthisinterviewcycle,9participantswereinbetweenintervention

weeks30and52,andfor11participantstheaccesstothesystemhadalready

ended,rangingfrom2to27weekssincetheendoftheHBCSSintervention

period.Oneoftheindividualsendedhisparticipationduringtheresearch

project;therefore,theinterviewmaterialincludesresponsesof43Onnikkausers

insteadof44.

Thestrategyforchoosingtheintervieweeswastohaveawiderepresentationof

various“voices”[40].Beforetheinterviews,awidevarietyofactiveandnon-

activeusers(2–500,MED=61)wasidentifiedbasedonOnnikka’slogin

information.Simultaneously,thegoalwastokeepabalancebetweenfemales(n

=22)andmales(n=21);andwhetherornottheyhadgroupcounseling(2or8

times).Participants’agesrangedfrom22to61(M=47.1),theirbaselineBMI

rangedfrom27.2to34.8(M=30.5),andthetotalnumberofsystemlogins

rangedfrom2to500(MED=61).ForOnnikkausers,itwasrecommendedtolog

intothesystematleastonceaweektoreadthenewcontentthatwasprovided

byhealthprofessionals.Thesystem’suseadherencerangedfrom4%to100%

(M=62%;MED=71%)amongtheinterviewedparticipants.UtilizingOnnikka’s

useinformationmadeitpossibletoselectindividualswhowereatthefurthest

endsofthesystem-usecustoms.Forexample,participant42made1677entries

inthefooddiaryalone,butcontrarilyparticipant31hadahighadherencelevel

(94%)butrarelyusedthesystem’stools(atotalofjustfourentriesatthetimeof

conductingtheinterview).FollowingPatton’s[41]descriptions,thistypeof

samplingmethodisbestdescribedasmaximumvariation(heterogeneity)

sampling,wherethegoalistodescribeandcapturecentralthemesthatemerge

fromtheheterogeneity.

ThefollowingsevenguidelinesproposedbyMyersandNewman[40]were

appliedwhenconductingtheinterviews:

1)Situatingtheresearcherasanactor.Beforethebeginningoftheactual

interview,theresearcherexplainedtheprocedureoftheinterview,howthe

collecteddatawouldbeused,andexplainedhowtocontacthimafterwards.The

researcheremphasizedthathewasneitherahealthprofessionalnorinvolvedin

thesystem’scodingprocess,andthereforewasaneutralactorwithregardto

Onnikka.

2)Minimizesocialdissonance.Thepositioningoftheresearcherasaneutralactor

helpedtominimizesocialdissonance.Duringtheconversation,theinterviewer

sympathizedwiththelifesituationoftheparticipantandopenlymade

correspondingremarksconcerninghisownlife.InFinland,wheretheinterviews

wereconducted,societyisrelatively“flat,”sonoextrapreparatoryeffortwas

neededtominimizethesocialdissonancerelatedto,forexample,age,gender,or

socialstatus.

3)Representvarious“voices.”Thestrategyforselectingtheparticipantsforthe

interviewwastoobtainthesamenumberofmalesandfemalesfromallthree

counselinggroups.Theaimwasalsotohavethesamenumberofparticipants

whoobtainedtailoredinformationandthosewhodidnot.Beforetheinterview,

Onnikka’slogininformationwasusedtorecognizeagoodvarietyofbothactive

andnon-activeusers.Duringthelaststagesofthisresearchcase,separatetools

onparwithindividuals’BMImeasurementswereusedtoselectparticipantsfor

interviews.

4)Everyoneisaninterpreter.Thisstudyisaninterpretivecasestudy,anditholds

theideathattheworldissociallyconstructed.Interviewingisarareeventfor

participants,andcollectedresultsshouldbeconsideredasinterpretationsrather

thanindisputablefacts.

5)Useofmirroringinquestionsandanswers.Eventhoughsemi-structuredlistsof

questionswereprepared,mirroringwasusedduringthecourseofthe

interviews.Mirroringmeansconstructingasubsequentquestionorcomment

usingsubject’swordsandphrases,whichallowstofocusonthesubjects’world

view[40].Theorderofquestionsandtheirexactwordingcouldvaryaccording

tothethemesthattheparticipantwasdescribing.Moreover,iftheparticipant

hadnotusedcertaintools,orhe/shehaddifficultyrememberingthem,someof

thequestionswereomitted.

6)Flexibility.Participantswereencouragedtospeakspontaneously,andallof

thoseinterviewedweregivenallthetimetheyneededfortheinterview.The

durationofasingleinterviewvariedfrom25minutestoalmost2hours.

7)Confidentialityofdisclosure.Permissionwastakentorecordtheinterview

beforebeginningtheactualinterview.Toensureconfidentiality,onlyresearch

numberswereincludedintherecordingssothattheycouldbelinkedwiththe

system’suserdata.Thecodesinthisstudyaredifferentfromthenumbersstored

intherecordings.

3.1 Hermeneutic Research Thisstudyispartoftheinterpretivequalitativeresearchtradition,anditleans

heavilyonhermeneutics.Oneofthemaincharacteristicsofinterpretivismis

seeingrealityassociallyconstructed[42].Participants’answersduringan

interviewareinterpretationsoftheirinitialmotives,andresearchers’

conclusionsfromthecollectedmaterialareinterpretationsaswell,whichare

madeinacertainsituationalcontextorfromacertainstandpoint[43,44].Patton

[14]arguesthatthisperspectiveisfundamentalinqualitativeinquiryandhas

becomecommonplaceincontemporarysocialscience.

KleinandMyers[42]suggestasetofprinciplesforinterpretivefieldstudies,and

consideredthehermeneuticcirclethefundamentalprincipleofinterpretivism.

Typicallythisisseenasanoverallontologicalapproachforinterpretivestudies,

andthereareonlyamodestnumberofstudieswherehermeneuticalapproaches

havebeenappliedasaresearchmethodology,asSarkerandLee[45]argue

(Karppinenetal.[46]usehermeneuticstostudyanomaliesfornon-adoptionof

BCCS).Asaresearchmethod,hermeneuticsoriginatesfrominterpretingancient

texts,inwhichstrivingtodeterminethecorrectunderstandingofatextledto

therecognitionthatitispracticallyimpossibleforhumanstoretrievea“true”

100%representationofatext[44].Subsequently,hermeneuticshasbeen

portrayedasthetheoryoftheinterpretationofmeaning[47,48].Accordingto

theprinciplesofthehermeneuticcircle,thedevelopmentofaninterpretationis

aniterativeprocess,wheretheunderstandingofthewholeoccursthroughthe

meaningoftheseparateparts,andthemeaningofseparatepartsisdetermined

bythewhole[41,42,45].Suchaninterpretationdoesnotassignequal

significancetoeachwordora“randomsample”ofwords[45].Yet,hermeneutic

interpretationisnotintendedtoreplacepositivistqualitativeresearchbutrather

strengthenandcomplementit(seee.g.[49]).Previously,TrauthandJessup[50]

demonstratedhowinterpretiveanalysisiscapableofproducingnewinformation

thatcouldnotbefoundthroughpositivistapproachesandnovelunderstanding

ofevidenceevenfromdatathatwasalreadyanalyzed.

Hermeneuticsisavaluabletoolforinterpretingqualitativedata[45]becauseit

makesuseofanomaliestogainabetterunderstandingoftheinformationina

particularcontext[47,50].Itisfairlycommoninhermeneuticresearchtradition

thatthemesandcategorieschangeduringiterations,andresearchersmaycollect

moredatabetweenthecircles[45].Whenallnewlygainedknowledgeisrelative

topriorunderstanding,aresearcher’spre-understandingisthestartingpointfor

ahermeneuticstudy,andthusitalsoprovidestheinitialinterpretiveframework

[47].AsColeandAvison[47]outline,aresearcher’sprejudicesarethebasisof

theresearchprocess.Inthisresearchcase,thethreemostessentialelements

concerningpre-understandingweretheBCSSframework[19],thePSDmodel

[23],andtheactualsystemitself(introducedintheprevioussections).Theories

wereusedaslensestoexplaindataratherthantoverifythetheoriesthemselves

orbuildnewones.

Hermeneuticsdoesnotofferexplicitguidelinesonhowtoconducttheactual

dataanalysis.Certainresearchersuseanalysisproceduresfromother

methodologies,suchasopencodingfromgroundedtheory[51]ordiscourse

analysis[52].Thisstudydoesnotfollowanyspecificmethodologicalschool;

instead,thegeneralprinciplesofcodingandindexingwereutilized,which,as

statedbyMilesandHuberman[53],arethemostcommonpracticeinqualitative

dataanalysis.Alltheinterviewswereconductedviaphone,recorded,and

transcribed.NVivo10softwarewasusedtomanagecodesandcategories,but

noneoftheautomatedclassificationtoolswereutilized.Dataanalysiswas

conductedbythefirstauthor;however,inhermeneutics,itisnotuncommonthat

onlyoneauthordoestheanalysis(e.g.[47]).Itwasconsideredthatthesame

authorwhointerviewedparticipantshasthebestunderstandingoftranscribed

texts.Abilitytorecognizetonesandothersubtlevocalcueswereperceived

important.Firstandsecondauthorhadreflectionmeetingsthroughoutthe

processofdatagathering,analysingthedata,andhowthesynthesisofthe

findingswasmade.Especiallyafteranomalousfindingsfromthefirstinterviews,

discussionswithsecondauthorhelpedtoevaluatethedecisiontrail.

Duringthisresearchcase,interviewswereconductedinthreehermeneutic

circles,andinterviewswerebasedonanevolvingsetof(primarily)semi-

structuredquestions.Thethemesofthequestionsvariedfromtechnology

acceptancetoflowexperience,andfrompersuasivesystemfeaturestochanges

inattitudesandbehaviors.Sincethequestionswerepreparedinadvance,avast

majorityofthecodeswerecreatedpriortotheinterviews.AsMilesand

Huberman[53,p.65]argue,itiswiseforaqualitativeresearchertocreatecodes

moreinductivelyandanalyzecollecteddataforempiricallydrivenlabels.As

Stahl[44]haveargued,hermeneutics(asemphasizingunderstanding)issuited

tothosesocialsituationsthataimtounderstandhumanactivities,nottopredict

them.

Onnikkawasnotdevelopedwiththehabitformationframeworkinmind,asthe

primaryaimofthesystemwastosupportparticipants’attitudechange.Yet,

basedontheexperiencefromthefirsthermeneuticcycle,itappearedthathabits

couldplayaroleinHBCSSuseandintheactualbehaviorchangeprocess.Inthe

followingexample,theroleofhabitisratherevident.Sectionsthatwerelabeled

with“habit”codesareunderlined,andcommentsinthebracketsrepresentthe

interviewer’sinterpretations.

Interviewer:HasOnnikkabeenhelpfultoyouwhenmaking

changestoyourlifestyle?

Participant11.Yes,ithas.EverytimeIgrabaproduct[ina

grocerystore],Istarttothinkiftheneedforitisreal,orisit

moreofahabit.Ithinkit[Onnikka]isagoodtoolforthat.And

alsowhenIgotothefridge.Whenit’s[lifestylechange]inthe

backofmyheadsomehow,itmakesmethink,whattochooseand

whatnot.

Interviewer:HaveyoulearntnewthingsbyusingOnnikka?

Participant11:Yes,Ihave.Itgivesmemoreunderstanding.Like

ifIcontinuelikethis,wherewillitleadme?Andkindofalsohow

healthandeatingareconnected.Ithasbeenveryuseful.When

I’vegottenusedtoacertainrhythmorpattern,Ihaven’thadto

thinkfurther.I’vebeenabletojustletitgoandlivemylife.

Interviewer:DoesOnnikkachallengeyouenough?

Participant11:Yes,itdoesquitesufficiently.It’snotstagnantall

thetime,anditgivesnewperspectiveswhenthinkingabout

personalgoals.Whenforinstancethetopicwasexercise,itdid

helpmebecomemoreactive.Nowit’smoreorlessahabitthatI

justgo[toexercise].Whenexerciseisincluded,it’sagood

reminderthatit’stimetobeactive.

Twohabit-relatedquestionswereaddedforthesecondandthirdhermeneutic

circles:first,participantswereaskediftheyfeltthattheiruseofOnnikkahad

becomeahabit;andsecond,participantswereaskedwhethertheystillhadto

strugglewiththeirlifestylechangeorwhetherthenewbehaviorshadbecomea

habit.

Previousstudies(e.g.,Karppinenetal.[37])havehighlightedtheimportanceof

threepersuasivefeaturesforusersofOnnikka:self-monitoring,reminders,and

tunneling.Moreover,newweeklycontentwasperceivedasaveryinfluential

partofOnnikkabymanyoftheparticipants.However,ithasremainedunclear

whythesespecificfeatureswereperceivedsohighlyamongsystemusers.

4 Stages of Habit Formation Creatingahabitplaysanimportantroleinhealthbehaviorchange,asmany

healthgoalsarereachedonlybyrepeatedaction.Habitsareconsideredtoplaya

fundamentalroleinbehavior,andtheformationofhealthyhabitsmaybethekey

toaidmaintenancebeyondtheinterventionperiod[54].Althoughhabitsare

knowntoaffectbehavior,promotinghabitformationisarelativelynovel

researchareainthehealthpsychologyfield(24,54].

Inpsychology,habitsareconceptualizedasbehavioralpatternsenacted

automaticallyinthecontextinwhichthebehaviorhasbeenconsistently

repeatedbefore[24,55,56].Gardner[54]determinesahabit“asaprocessby

whichastimulusautomaticallygeneratesanimpulsetowardsaction,basedon

learnedstimulus-responseassociations.”Gardner[54,p.4]considersahabittobe

animpulsivepathway,wherecontext-behaviorassociationsrapidlyand

efficientlypromptbehaviorwithminimalforethought.Onareflectivepathway

arereasonedcognitions,whichdirectbehaviorslowlywithdeliberateeffort[54].

LallyandGardner[24]suggestfourstagestoachieveautomaticity.They

considerahabitasacontinuum,whereautomaticityisconsideredastrength

ratherthanadichotomy(havingornothavingahabit).Nevertheless,distinctive

stagesofferausefulconceptualizationfromapracticalperspective.Accordingto

LallyandGardner[24],forabehaviortochange,adecisiontotakeactionmust

firstbemade.Second,theintentiontoacthastobetranslatedintobehavior.

Third,thebehaviormustberepeatedinthepresenceofthesamecontextualcues

toformahabit.Afterhabitstrengthpeaks,repetitionhaslittleimpactonhabits

[57]and,consequently,thefourthstagepertainsexclusivelytohabitformation.

Thenewactionmustberepeatedinafashionthatisconducivetothe

developmentofautomaticity,whichincludescreatingsalientcuesforthe

activity,emphasisonconsistency,reducingbehavioralcomplexity,andavoiding

extrinsicrewardsthathavethepotentialtohinderthehabit-formationprocess

[24].

Inadditiontoformanewhabit,breakingoldhabitsareimportant.Despitebeing

motivatedtoperformanewbehavior,whenanopportunityarises,many

individualsactaccordingtotheiroldhabits[24,56].Itispossibleforhabitual

behaviorstobeautomatic,yetinfrequent[54],andthese“implicithabits”offer

oneexplanationforwhybehavioralinterventionstypicallyyieldshort-term

gains,whicharelikelytoerodeasoldbehaviorsre-emerge[54,58].

5 Results Inthissection,wefirstdescribehowtheresponsesofindividualsinthisstudy

mapwithLallyandGardner’s[54]habitformationstages.Second,wesummarize

howtheindividualsperceivedtheformationofHBCSSusehabitandbehavior

changehabit.

5.1 Intention Formation Stage Participatinginthisresearchprojectwasvoluntaryandfreeofcost.Atotalof

12,500invitationlettersweresenttoFinnishcitizensintheNorthern

Ostrobothniahospitaldistrictarea.Committingtobepartofaresearchproject

withitsbaselinemeasurementswassuchathresholdformanyparticipantsthat

intentionformationwasnotacriticalelementwhenparticipantsobtainedaccess

touseOnnikka.Ingeneral,participantshadhighmotivationtoachievealifestyle

changewhentheybegantousethesystem.Forsomeparticipants,eventhe

thoughtofbeingpartofthelifestyleinterventionstudywashighlymotivating,as

thefollowingquotationreveals.

P36:“Invitationletterhelpedalot.Gettingintothiskindof[research

project]islikewinninginthelottery.”

Thepsychologicalpredictorsofintentionformationhavebeenthefocusof

severaltheories[e.g.,59,60,61],buttheyarenotemphasizedinthisstudy.

5.2 Translating Intention into Action Stage Decisionsaresignificantpredictorsoftheinitiationofbehavior,but“intention-

translation”isnotalwaysperfect.Sheeran’s[62]reviewrevealedthatamong

thosewhointendedtoengageinacertainbehavior,theaveragerateof

performancewasmerely47%.Thisgapcanbepartiallyexplainedbylost

motivationtoperformthebehavior[24].ThedurationofOnnikkaisunusually

long,asnewcontentandtasksareprovidedbyhealthprofessionalseveryweek

foratotalof52weeks.For3participantsoutof43,the“intention-behaviorgap”

wascausedbyalossofthemotivationtoperformtheaimedbehaviorquitesoon

aftertheyhadbegunusingOnnikka.Theyallexperiencednotfeelingtheneedto

useOnnikkaafterall,asseenfromthefollowingquotation:

P34:“Ibarelygotacceptedtothisresearchprojecttobeginwith.WhenI

attendedagroupmeeting,IrealizedthatIdidn’thaveaweightproblem

[whencomparedtoothers],anditreallykilledmymotivationtouse

Onnikka.”

AccordingtoLallyandGardner[24],volitional(or“post-intentional”)factorsare

thesecondclassofreasonsthatcanexplainwhypeoplefailtoactontheir

intentions.Thesefactorsarerelatedtotheabilitytoputplansintoactionand

rememberingthem[24].Mosteffectivecuestoactonaplanaredistinctevents

indailylifethatarebarelymissed.Self-monitoringcanalsobeparticularly

meaningfulinrequiringreliableevaluationsofcurrentbehavior,sothat

differencesbetweencurrentactivitiesanddesiredbehaviorcanbeperceived

[24].Arepresentativeexampleshowshowparticipant01begantomeasurehis

weightfirstthinginthemorning:

P01:Beforethis,Ihadn’treallybeenonthescaleinthemorning,butnowI

weighmyselfatleastonceaweek,usuallymorethanonce,andwhatis

greatisthatit[Onnikka]drawsthatgraphsoit’sverynicetoseeitgoing

downwards.Ofcourse,itsometimesgoesflatandevenupwards,butstillit

hasbeendroppingdownthewholetimeafterIstartedusingit.It’sbeen

greattofollowit.

SupportisofferedtoHBCSSusersbyenablingthemtokeepupwiththeir

lifestylechangebyprovidingthemreminders.EvenmostOnnikkauserswho

werenotactiveusersperceivedremindersasapositivefeature:

P25:“There’sbeenquiteabitofeverythinggoingoninmylife,andtheweb

systemhasbeenputonthesideforawhile.It’sinthebackofmymind

anyway,andbecausethesystemremindsme,Iatleastreadthecontent

everyweek.WiththehelpofOnnikkaIgetself-control,andIcanwalkaway

fromtoughsituations.”

Whenlosingweight,knowinghowtodealwithasocialsituationinwhichhigh-

caloriefoodsareofferedcanbeextremelydifficult.AccordingtoLallyand

Gardner[24],bothaction-planningandcoping-planninghavebeenconfirmedto

assistbehaviorchangewhenusedindependentlyorincombination.Participants

diddescribetheirplanstochangetheirlifestyles;however,somewhat

surprisingly,participantsgaveonlyafewconcreteexamplesofhowspecifically

Onnikkahadsupportedtheirplanning.

5.3 Repetition Repetitionoftenrequirescontinuedintrinsicmotivationandthesupportofself-

regulatorytechniques[24,31,63].Inaddition,goal-directedactionsthat

generatepositiveemotionscanstrengthencommitmenttochange(Louroetal.

2007),andself-monitoringcanbeonetooltorecognizeanticipatedoutcomes

[24].Duringtheearlystagesofbehaviorchange,actionsthatgiverisetopositive

emotionscanincreaseeffort,whereasthosepromptingnegativeeffectsaremost

likelydiscontinued[24,57,64].Asbehaviorsarerepeatedandautomaticity

beginsemerging,theinitiationofabehaviorrequireslessereffortand,therefore,

participants’satisfactionmaybestrengthenedbyfocusingontheeaseof

performance[65].TheOnnikkasystemitselfwasperceivedaseasytouse.Nota

singleinterviewedparticipantsaidthatthesystemwastoodifficulttouse.In

addition,Sharpeetal.[22]foundthateaseofusewasanimportantfacilitatorof

enhancedengagement.

Duringthelongspanoftheintervention,manyparticipantswerefacedwiththe

situationinwhichtheirweightlosshadstalled.Therewereevenafewuserswho

seemedtobediscouragedbythemonitoringofweightafterasetback.The

followingquoteisagoodexampleofhowpositiveoutcomescanenhance

behaviorchange,andhowunexpectedobstaclescanturnintoadownward

spiral.

P39:I’vealwaysbeenphysicallyactive,butthistimeIalsochangedmydiet.

Followingtheweightcurvewasverymotivating,andinthespringIalmost

achievedmyweighttarget,from96to80kilos.Ihadamedicalissueduring

thesummerandcouldn’texerciseregularly.Paradoxically,Iatemore

despitethefactthatIdidn’tconsumeenergynearlyasmuch.SoIgained

moreweight,andIhaven’tgonetothescalesince.ButnowthatIcan

exerciseagain,andIknowhowtokeeptheweightundercontrol,Ibelieve

I’llsucceed.

Incaseoffacingasetback,onemethodtohelprepetition,accordingtoLallyand

Gardner[24]istheabilitytoswitchfocustodifferentdomainsofsuccesswhen

needed.Participant38hadhighself-esteemandwasveryoptimisticdespitethe

factthatshehadnotlostweightinayear.

P38:Ihadn’tlostweightwhenIhadmyone-yearmeasurement.Butmy

waisthasgonesmallerandmycholesterollevelsaremuchbetter.Mynew

habitistoeatmorefrequently,afterevery3hours.ButIstillneedto

restrainmyself;mybiggesturgeisforsugar.

Afternewbehaviorhasbeeninitiated,self-monitoringcanmakethecompliance

withbehavioralgoalseasier[24].Monitoringcansupportcontextualstabilityto

ensurethatindividualsareperformingthebehaviorinthesamewayoneach

occasion,whichinturnhelpshabitformation[24].Forseveralparticipants,it

wasparticularlydifficulttoprogresswithweightmanagementintheholiday

season.

P31:Ifeltthatmywillpowerwascrackingduringthesummer.Ithinkmy

biggestachievementsofarwasthatIsurvivedthroughit.EverytimeI

noticedthatmyweightstartedtorise,Ilightenedupmydiet.IfIatetoo

muchduringtheweekends,Itookmyselfbackontrackimmediatelythe

nextweek.

Thebenefitsofself-monitoringcanbeenhancedbyprovidingfeedbackon

performance,whichcankeeppeoplemotivatedduringtheacquisitionphase[24

31].TheOnnikkasystemgavepositivesupportivefeedbackwheneverthe

individualsubmittedhis/herweightinthesystem.However,thispraisefeature

wasrarelymentionedbytheintervieweesifnotspecificallyrequested,andits

meaningseemedrathertrivialforthem.

Positivereinforcementcanalsobepromotedbyexternalfeedbackbyhaving

otherscommentonperformance[24].ParticipantsinOnnikkacouldmake

commentsonweeklythemesandwereabletosharetheirthoughtsanonymously

usingpseudonyms.Unfortunately,thisfeaturewasusedbytheparticipantsso

scarcelythatitbarelycreatedanysenseofsocialsupportamongthe

participants.Fiveparticipantsperceivedlackofsocialsupportasoneofthekey

reasonsfornotusingthesystemthroughouttheentireinterventionperiod.

LallyandGardner[24]arguethatpeoplewhoareengagedinbehaviorchange

shouldbeprovidedwithsupporttoachieveself-directedchangesratherthanto

followexternalinstructions.Supportforcompetenceandautonomyare

hypothesizedtointeractwitheachother,therebymakingbehaviorbebetter

internalized[66].Inthecurrentresearchcase,participantswereawareofthe

importanceofgainingcompetenceandautonomyingeneral;nevertheless,our

dataholdsanswersthataresomewhatcontradictory.InOnnikka,therewasa

sectionforfrequentlyaskedquestions,butdespitethepossibilityofreceiving

informationdirectlyfromhealthcareprofessionals,someuserswere

disappointedthattheirrecordingsinthesystemwerenotmonitoredand

commentedonbyexperts.Infact,thecommitmenttousethesystemas

instructedwasoftenmentionedinpositivelightduringtheinterviews,andfour

participantsstatedthatcommitmentwastheirprimaryreasonforusingthe

system.

5.4 Automaticity LallyandGardner[24]notethat,traditionally,ithasbeenassumedthatif

performanceishighlyrewarding,thelikelihoodthatabehaviorisrepeatedis

high[67],andhabitsdeveloponlyifrewardsarereceivedforeachrepetition.

Conversely,recentstudieshaveshownthatprovidingnotableandtangible

rewardsforbehaviorcanundermineintrinsicmotivation,andextrinsicrewards

enhancehabitformationonlywhentheydonotbecomethegoalofbehavior[24,

68].ParticipantsinthePrevMetSynresearchprojectdidnotgetanyrewardsfor

participating.Almostallinterviewedparticipantsdidnotreporthavingany

extrinsicrewardsoftheirowntohonortheirweightlosseither,andthosewho

did,hadmoderaterewards(e.g.,glassofwine,smaller-sizetrousers,sport

equipment).

LallyandGardner[24]emphasizethatsimpleactivitiesareeasiertoautomate

thancomplexbehaviors.Intheflowofeverydayroutines,behaviorsareoften

linkedtogetherin“chunked”sequences,sothatthecompletionofoneactivity

cuesthenext[29].SeveralOnnikkauserswereunabletofindspacefortheuseof

HBCSSintheirflowofdailyactivities:

P24:“Ihaveathree-shiftjob,I’masinglemother,andIhavealotof

hobbies.I’maverydiligentperson,soifIforgettouseOnnikka,Ifeel

miserable.SometimesIpanicwhenIrealizehowquicklytheweekhas

gone.”

Individualshadtheentireweektoreadtheweeklycontentandsubmittheirself-

monitoringentries,andthereforethesystemwasnotbelievedtobetootime

consuming.Surprisingly,alackoftimetoutilizethesystemtothefullwasa

rathercommonargumentfornotusingOnnikka,andsixparticipantsindicated

thatthiswasthemainreasonthattheydidnotusethesystem.Paradoxically,

respondentswerenotcriticizingOnnikka’sunchangeablerhythm,whichfollows

theprincipleofpersuasivefeaturetunneling;rather,theyperceivedtunnelingas

avaluablesystemfeature.

P02:“Theinvitationtopartakeinthisresearchcameataveryopportune

momentbecauseIknewthattherisksofgettingsickwerehigh.Mylifeis

reallyhectic,soI’mabletoconcentrateonthissincethere’sthisscheduling.

NowI’mdoingthethingsthatIshouldhavedonemuchearlier.Appointed

meetings,oransweringthequestions[inOnnikka]makesiteasiertofocus

onthings.--IlogintoOnnikkacoupleoftimesaweek.Icheckmyweight

weeklyandwritemythoughtsthere.AndIalsomarkmyexercisethere.--

Thesurestwaytosucceedwouldbenothavinganysociallife…livingina

bubble.Thetrickishowtocopewiththeexceptionsandmakingyour

lifestylechangeongoing.”

LallyandGardner[24]discusswhethertheroleoftheuninterrupted

performanceofbehaviorisanecessaryconditionforhabitformation.Armitage’s

[70]studyshowedhowexercisehabitsdevelopovera12-weekperiod,andit

wasfoundthatlapsesinperformingthebehaviorpredictedpoorerfuture

performance.Lallyetal.[57]foundthatonemissedopportunitydidnothavean

impactonhabitformation.Inourresearchcase,onlyparticipant31identified

interruptedperformanceasareasonfornotcontinuingtousethesystem.Itmay

alsobethatuninterruptedperformancedidnothaveasignificantimpactinsuch

alonginterventionperiod.InOnnikka’slong52-weekICTinterventionperiod,

therewereonlyafewparticipantswhousedthesystemeveryweekthroughout

theyear,andoccasionalbreakswerenotperceivedascritical.

5.5 Breaking Unwanted Habits Onnikkaenabledindividualstobreaktheiroldhabitsbyhelpingthemtoraise

awarenessoftheireverydaychoicesandeventuallybuildhealthierhabits

throughrepetition.LallyandGardner[24]arguethatanappealingsolutionto

breakoldhabitsistoremovetheindividualfromanyenvironmentthatcues

unwantedhabitualresponses.Inaddition,remindersintheenvironmentarea

usefultooltohelppeopleremembertheirplans,ifplacedappropriately[71].

AmongOnnikkausers,onlyafewmentionedplacingremindersintheir

environment:

P32:“Onnikkaisaveryimportantreminderandsupporter.Ihavethree

kids,sowhenthey’vegonetobed,havinglatenightsnackswhilewatching

TVhasbeenmywaytorelax.NowIputaglassofwateronthesofa’s

armresttoremindmeofmybehaviorchangeproject.”

However,eventually,ratherthantryingtoforeveravoidcuesthattrigger

unwantedhabits,newalternativeresponsesareneeded[24,72].Vigilant

monitoringoffersaneffectivewaytoinhibitunwantedhabitsbypaying

attentiontopotentialslipups,whichinvolvesthe“don’tdoit”thoughtprocess

[45,62].Self-monitoringwasoftenperceivedasaneffectivewaytoinhibit

unwantedhabitsamongOnnikkausers.

P42:Asapensioner,IhadplentyoftimetouseOnnikka,andItypedwhatI

ateeverydayforawholeyear.IfIhadtoaddachocolatebarthere,I

couldn’tlookmyselfinthemirror.

5.6 Experiences of HBCSS Use Habits and Lifestyle Habits Forthelastphaseofthisstudy,theweightresultsforthetwelfthmonthwere

collected,andOnnikka’susedatafortheentireinterventionperiodwere

collected.Thepossibilityofusingweightinformationandsystemuseactivity

servedasnewlensesofinterpretation.Onnikkauserswererecommendedtolog

intothesystematleastonceaweektoreadtheprovidedcontent.InFigure1,

participantswith100%adherenceloggedintothesystematleastonceaweek

throughouttheentire52-weekinterventionperiod.Figure1presentsdetailson

theparticipantsinterviewedinthesecondandthirdinterviewcircles(total31).

Figure1.Responsestohabitformationfromthesecondandthirdinterviewcycles

Whenselectingtheparticipantsforinterviews,theaimwastofindthesame

numberofactiveandinactiveusers.Therefore,itmustbenotedthatthecoloring

ofuseadherenceinFigure1doesnotpresentathresholdfoundintheliterature,

wherethesystemusewouldhavebeenfoundtobeparticularlybeneficial.The

system’suseadherencerangedfrom4%to100%(M=62%;MED=71%)among

theinterviewedparticipants.Atotalof15respondentshadlessthan50%system

useadherence,fromwhichallbutoneparticipantsaidthatusingOnnikkanever

becameahabit.Individualswhohadover50%adherenceclaimedalmostthe

exactopposite:11participantsoutof16claimedthatusingOnnikkawasmoreor

lessahabitforthem.

Theanswersrelatedtobehaviorchangeasanewlifestylehabitweresurprising.

Fromamongninerespondentsthatmanagedtolose5%oftheirweightinayear,

onlyfourstatedthattheirnewlifestylewasanautomatedhabitatthetimeofthe

interview.Naturally,intheseanswers,ithastobetakenintoaccountthatforthe

mostpart,theinterviewswereconductedindifferenttimeperiods,and—for

exampleintheinterventionweeks25–27—participantsgenerallyseemedtostill

bestrugglingwiththeirlifestylechange.Anotherunexpectedfoundingisthat10

participantsexpressedthattheyreachedautomaticityregardingnewlifestylesat

thetimeoftheinterviewsbutwerenotabletolose5%oftheirweightattheir

12thmonthmeasurements.

6 Discussion Self-monitoringtools,remindersandtunnelingappearedtooffersupportto

committotheintervention.LallyandGardner’s[24]stagesofhabitformation

wereusedtocategorizethefindingsofthisstudy.AsevidentfromLallyand

Gardner’s[24]habitformationmethods,self-monitoringandremindersworkin

multiplestages.Thismightbeoneexplanationforwhyself-monitoringand

reminderswereperceivedasrathervaluableinthisresearchcase,andwhy

empiricalstudieshavefoundthemtoplayaprominentroleinchangingphysical

activityandeatingbehaviors[31].Interventionsnotincludingself-monitoring

havebeenfoundtobesignificantlylesseffectivethaninterventionswith

monitoring[31].Textmessageshavebeenfoundtoincreasephysicalactivity

whencomparedtocontrolgroupswhodidnotreceivereminders[73].Itmustbe

notedthatinourstudy,remindersandtunnelingwerevaluedalsoby

interviewedparticipantswhowerenotabletoachieve5%weightlossafterthe

interventionperiod[37].Moreover,newweeklycontentwasperceivedasavery

influentialpartofOnnikkabymanyoftherespondents.Theprovisionof

frequentupdatesisimportant,afindingthatisalsosupportedbythereviewsof

Brouweretal.[18]andKeldersetal.[21].Eventhoughnotaseparatepersuasive

softwarefeature,“frequentupdates”arerelatedtothefourthdesignpostulateof

thePSDmodel[23],namelythat“persuasionisoftenincremental.”

OurresultsimplythatsystemuseadherenceandHBCSSusehabitsarerelated;

however,perceivedlifestylehabitsdidnotappeartocompletelyresonatewith

theactual5%weightlossamongparticipants.Formanyrespondents,anew

lifestyleimpliedabehaviorchangeinoneparticulararea;forexample,

participants37and43statedthattheyselecthealthyfoodingredientswithout

beingconsciousofitanymore,participants29and33statedthatexercisinghas

evolvedtothelevelofautomaticityforthem,andparticipants34and36said

theireatinghabitsarenowhealthy(smallerportionsandregulareatingtimesto

avoidbingeeating).AccordingtoLallyandGardner[24],performingmultiple

behaviorsinresponsetoonecuecandiminishthepossibilitiesthatanyresponse

willbecomehabitual[74].Ifmanybehaviorscanbeusedtoachieveagoal,the

associationbetweenthegoalandanyonebehaviorisreduced[24].Withthe

Onnikkasystem,usersalsoexperiencedtheoppositeprobleminthatone

behaviorwasoftennotsufficienttoachieveagoal,butmultiplebehaviorswere

requiredtodoso.Thiscanbeoneexplanationforwhyparticipants’perceived

lifestylehabitsdidnotappeartoresonatewiththeiractual5%weightloss.The

reportedautomaticityoftenconcernedonlyoneareaoutofmanythatwould

haverequiredweightmanagement.HBCSSsdesignedtoachieveacomplete

lifestylechangecouldhelpitsuserstoswitchtheirfocustodifferentareaswhen

needed.

Onnikkadidnotoffermuchsocialsupport,whichclearlyinfluencedtheuser

experienceforsomeparticipantsdirectly.Maheretal.[75]discoveredthat

health-focusedonlinesocialnetworkscanbeeffective,butapproximately50%

ormoreofuserswhosignupdonotremainfortheentiredurationofthe

intervention,andengagementisgenerallylowforthosewhodostay.Maheretal.

[75]speculatesthatadrawbackofhealth-focusedonlinesocialnetworksisthat

theyattractmotivatedindividualswhowerealreadymotivatedtochangetheir

healthbehavior.Sharpeetal.[22]arguethatthetypeofsocialsupportmaydiffer

dependingonusercharacteristics.OurresultsseemtoagreewithLehtoetal.

[32]andKrukowskietal.[76],whoindicatethatinonlinecommunities,peer

supportgainsimportanceinthemaintenancephase.Ittakestimefornewusers

todevelopanaffectivecommitmenttothecommunity[32],anditisunfortunate

thatusersarenotabletogarnersocialsupportwhentheyareinneedofit.

6.1 Implications for Practice Accordingtoourresults,inadditiontoself-monitoringandreminders,tunneling

isalsoaveryinfluentialHBCSSfeatureandshouldnotbeoverlookedwhen

designinge-healthinterventions.Thisisannoteworthyfindingespeciallysince

intheiranalysisofwidelyusedweight-losswebsitesLehtoandOinas-Kukkonen

[77]foundthattunnelinghadnotbeenutilized.

Participantsencouragedtoperformahealth-promotingbehaviorregularlyin

unvaryingcontextswereshowntohaveanincreasedhabit-relatedautomaticity

[57,65].Ourresultsshowhowchallengesineverydaylifeoftenareapartofthe

reasone-healthusersdonothavethecapacitytoparticipatefullyinthebehavior

changeprocess.Therefore,e-healthdesignersshouldnotonlyfocusonthe

repetitionofabehavior,butalsoprovideameanstosettletheactualusecontext.

LallyandGardner[24]underlinethatsimpleactivitiesareeasiertoautomate

thancomplexbehaviors.Itischallengingtoachieveacomprehensivelifestyle

change,andLallyandGardner[24]suggestlargetaskboundariesasthebest

pointtoinsertanewhabit;however,taskcompletionneedstohaveasalientcue

toincreasethechanceofanewplannedbehaviortobeperformed[71].People

makethemostactionslipsattheinterfacebetweentheendofonebehaviorand

theinitiationofanother,presumablybecausethelinktothenextactionisnot

strong[24].AfewstudieshavebeenconductedtoexaminetheKairos-moment

persuasionoftheuseratthebestpossiblemoment(e.g.[78]).Ourresults

underlinethatthequestionofrecognizingthebestmomentforpersuasion

meritsfurtherstudy.Inthefuture,HBCSScouldidentifyaperson’sidletime,

suggesthealthyactivity,andcreateasalientcuefortheformationofthisnew

habit.Withthehelpofsmartphones,HBCSScanalreadysupportaspectslike

copingwithfoodcravingsatthemomentofneed.Itappearsratherevidentthat

modernHBCSSsshouldbedesignedfirsttobemobile-friendly.Anotherquestion

iswhetheritisreasonabletobuilddifferentapplicationsfordifferentmobile

platformsortodevelopweb-basedinterventionsthatcanbeusedwithall

devices.

Table2summarizesthekeymethodsofhabitformationfollowingLallyand

Gardner’s[24]study;thesearealignedwithOinas-KukkonenandHarjumaa’s

[23]PSDmodelconcepts.Thetableisanattempttofindcossespondingelement

fromthePSDmodel,withwhatcertainhabitstagecouldbeachievedintheLally

andGardner’s[24]framework.ThePSDmodel[24]includeskeyelementsof

habitformation,anditcanbeausefuldesignaidtoenhancetheautomaticityofa

behavior,eventhoughitisnotaimedathabitformationperse.

Stages of habit formation, subcategories (Intention formation not included)

Corresponding construct in the PSD model

Translation of intention into action (only volitional/post-intentional categories included in the table) Remembering intended action Action and coping planning Rehearsal (F) Reminders and cues for the enactment of a plan Reminders (F) Self-monitoring Self-monitoring (F) Promotion of repetition Satisfaction regarding the experience Positive experience of a new behavior Ease of use and usefulness (P) Attaining anticipated outcomes Self-monitoring (F) Different domains of success Route (C, the Strategy) Enhancing intrinsic motivation Connection with others Social support (F; includes

multiple features from this category)

Competence and autonomy Autogenous technology (C, the Intent)

Positive feedback Praise (F) Self-regulatory strategies Planning, particularly coping planning Rehearsal (F) Self-monitoring Self-monitoring (F) Supporting the development of automaticity Enhancing intrinsic rewards Rewards (F) Consistency Tunneling (F) Reducing behavioral complexity Reduction (F) Creating salient cues Route (C, the Strategy) Breaking unwanted habits Discontinuing exposure to unwanted habit cues Use context (C) Reminders in the environment Reminders (F) Programming alternative responses Rehearsal (F) Self-monitoring Self-monitoring (F) Table2.HabitformationmethodsadaptedfromLallyandGardner[24]andthecorrespondingconstructsofOinas-KukkonenandHarjumaa’sPSDmodel[23].(P=PersuasionPostulate,C=PersuasionContext,F=SystemFeature.)

Withregardtothestageofautomaticity,ourresultsareconsistentwithLallyand

Gardner’s[24]ideathatextrinsicrewardsarenotnecessaryforhabitformation.

6.2 Implications for Research IntheBCSSframework,Oinas-Kukkonenstatesthatasustainablebehavior

changeoccursonlythroughanattitudechange[19].Thisnotionissupported

particularlybytwowidelyusedtheories,namelythetheoryofreasonedaction

(TRA)[59]andthetheoryofplannedbehavior(TBP)[79].However,during

recentyearsintheareaofhealthpsychology,cognitivetheorieshaveclaimedto

fallshortempirically[58]andhavealsofacedfiercecriticism.Accordingto

Schwarzer[61],thereasonedactionapproachisinadequate,asitdoesnottake

intoaccountprocessesinvolvingbehaviorchange.McEachanetal.[80]found

thattheTPBisaconsiderablypoorpredictorofbehaviorinlongitudinalstudy

design,whenparticipantsarenotstudentsandwhentheoutcomesaremeasured

objectivelyinsteadofusingself-reportedresults.Sniehottaetal.[81]radically

demand“retiring”theTPB.Despitethecritics’claims,intentionsdonotneedto

bebelievedtobeacounterpointtoautomaticity.AccordingtoGardner[54],a

habitcanbeconsideredamechanismthatcuesconsciousdecision-making,

whichinturnpromptsbehavior,ratherthanmanagestheproceduralenactment

ofbehavior.Similarly,whenbattlingwitholdunwantedlifestylehabits,Lallyand

Gardner[24]arguethatprogrammingalternativeresponsestocuesbringsthe

decisionstoconsciousness.Neuroimagingstudiessuggestthatwhenmultiple

responsesareactivatedsimultaneously,theprefrontalcortex—whichisinvolved

inthedeliberativedirectionofactions—isactivated[82,83].Theabilitytoexert

self-controlisimportant,andwhenapersonisponderingbetweentwooptions,

designersofhealthinterventionsshouldensurethatintentionstoperformnew

behaviorsremainprioritizedatthedecisionpoint[84].Thisremarkincisively

indicateswhypersuasionishighlyimportantforHBCSSs.Despitethe

developmentoftheBCSSframeworkandPSDmodel[19,23],thereisstillrather

littleunderstandingofhowHBCSSusersexperiencehabitformation,andexplicit

suggestionsfordevelopersonhowtosupporthabitformationviatheuseof

HBCSSsarealsofew.

Whilehabitformationcanbehypothesizedtohelpbehaviorchange,itis

nonethelesspossibleforpeopletoloseweightwithoutnecessarilyforminga

habit.Theultimatequestionofthetruenatureofbehaviorchangealsomerits

moreattention,asitwillprofoundlyimpactthedesignandstudyoffuture

HBCSSs.

Accordingtoourresults,itappearsthatforsomeoftheparticipantsthemere

participationinastructuredinterventionwasmoreimportantthanthecontent

oftheintervention.Inthisstudy,forseveralindividuals,thefamiliarityofthe

systemandforeseeablescheduleappearedtoreducethecognitiveloadand

madeiteasiertocommittothedesiredlifestylechangeprocess.Theneedfor

supportingcompetenceandautonomyisnotaclear-cutissueinthisstudy.

Accordingtoourfindings,manysystemuserswererathercontenttofollow

externalinstructions,whilesomehadhopedforevenstricterinterventionby

professionals.Althoughself-determinedbehaviorchangeisthenaturalgoalof

HBCSSs,ourresultssuggestthatthereisavastgreyareabetweenindependence

andcompliancethatrequiresfurtherstudy.Itcanbehypothesizedthatthe

“Doctor´sorder,”thatis,aprescriptionsimilartoanexerciseprescriptionwill

increaseadherence.Thus,inthefuture,wewillseektorecruithealthcarecenters

withdifferentpatientprofiles(urban,suburban,rural).Patientswhoare

consideredtobeathighriskwillberandomizedandgiveneithernormalgroup

counselingifatallavailableoraprescription.Patternsobserved Theoreticalimplications PracticalimplicationsBCSSusehabitscombinedwithpersuasivefeaturesofself-monitoring,reminders,andtunnelingcanhelpuserstocommit

Self-monitoringandremindersworkinmultiplehabitformationstages,whichcanbeoneexplanationwhyfeatureswereperceivedsovaluablebyparticipants

TunnelingfeatureshouldnotbeoverlookedwhendesigningBCSSs

Perceivedlifestylehabitdidnotresonatewith5%weightlossamongparticipants

Thetruenatureofbehaviorchangemeritsfurtherresearch

Whenapersonisponderingbetweenopinions,interventionshouldensurethatnewbehaviorsremainprioritizedatthedecisionpoint

AlackoftimetoutilizethesystemwascommonargumentfornotusingOnnikka

Studyingpersuasioncontextisanimportantresearcharea

Systemdesignshouldnotfocusmerelyonrepetition,butalsofindwaystoconstructspaceforahealthylifestyle

Participantswerelesslikelytousethesystemifitdidnotfitintotheirdailyroutines

Bestmomentsforpersuasionisunderstudiedarea

Inthefuture,HBCSScouldidentifyaperson’sidletime,suggesthealthyactivity,andcreateasalientcue

Forsomeindividualsthemereparticipationwasmoreimportantthanthecontentoftheintervention

Enhancingcommitmentandconsistencycanreduceparticipant’scognitiveload

Prescriptionofaninterventionmightincreaseadherence

Table3.Patternsobservedandtheoreticalandpracticalimplicationsbasedonthesefindings

6.3 Limitations Therearemultiplelimitationsinthisstudy.Onnikkawasnotoriginallybuilt

accordingtohabitformationstagesand,therefore,itispracticallyimpossibleto

ascertainwhethersomeofthemethodswereleftunmentionedintheinterviews

becausetheywerenotperceivedasbeingmeaningfulortheywerenot

implementedinHBCSSsufficientlyeffectively.Moreover,therearemanywaysto

studysystemuseadherenceinadditiontologinactivities(e.g.,timespentinthe

system,posts,pageviews).Finally,LallyandGardner’s[24]studywasnot

referredtoineverydetail,whichleavesroomforfutureresearch;forexample,

theimportanceofpersonalgoalsettingisnotdiscussedinthisstudy.Further,

thetermsandconceptsbetweentheframeworksintroducedinTable2arenot

identical.Thisleavesroomforfurtherresearchtoreconcilethesemodelsandto

createunifiedapproach.Thereliabilityofresultscouldalsobequestioned

becauseonlyonecoderanalyzedthedataset.

7 Conclusions ThisstudyoffersgreaterinsightintohowHBCSSscouldhelpinbreaking

unwantedhabitsandfosterahealthierlifestyleamongindividuals.

Understandinglifestylehabitsisimportant,ashabitspromptbehaviorwith

minimalcognitiveresourcesandcanbebeneficialinhealthbehavior

maintenance.

Inthisqualitativestudy,aHBCSSnamedOnnikka,designedaccordingtothePSD

model[23]andtheBCSSframework[19],wasusedasaresearchmedium.A

totalof43interviewswereconductedtostudyusers’experienceswithregardto

thesystem,andparticipants’weightmeasurementswereutilizedtointerpretthe

results.Theresearchapproachemployedwashermeneutics,whichleans

ontologicallytowardthesocialconstructionofreality,gainedthroughlanguage,

consciousness,andsharedmeaning.LallyandGardner’s[24]conceptualization

ofhabitformationstageswasusedasalensofinterpretation.Lallyand

Gardner’s[24]workprovidesapossibleexplanationforwhyself-monitoring,

reminders,andtunnelingwereperceivedasparticularlyvaluablefeaturesinthis

researchstudy.

Accordingtotheresultsofthisstudy,habitsplayadualroleinhealthBCSSs.Use

habitsappeartohaveastronglinkwithsystemuseadherence,whichinturn

mayproducebetterhealthoutcomesforindividuals.Perceivedlifestylehabits

didnotappeartoresonatewiththeactual5%weightlossamongparticipantsin

thisstudy.Acompletechangeinlifestyleisoftennecessarytoachieve

sustainableweightloss,whichinturnrequiresholistice-healthinterventions.As

aBCSS’scoreaimistoimpactindividuals’livesandhelpthemmanagelifestyle

changes,morestudiesontheuseofBCSSsintheiractualcontextsarenecessary

todiscoverhowdifferentpersuasivestrategiescanhelppeopleachievehealthier

lifestylesinpractice.

8 Acknowledgments Wewishtothanktheanonymousreviewersofthisarticlefortheirinsightful

comments.WewouldliketoexpressourgratitudetothePrevMetSynresearch

consortium,includingprofessorMaija-LeenaHuotari,PhDHeidiEnwald,and

KreettaAskola.WealsothankPhDHannuVähänikkiläforhishelptoimprovethe

manuscript.HOKwishestothanktheFinnishCulturalFoundationforsupporting

thisresearch.

9 Conflicts of Interest TheauthorsarepartoftheresearchteamthatdevelopedOnnikka,thebehavior

changesupportsystem.Thesystemhasbeendevelopedsolelyforresearch

purposes,withoutanycommercialinterests.

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