Exploring the Use of Persuasive System Design Principles to Enhance Medication Incident Reporting and Learning Systems: Scoping Reviews and Persuasive Design Assessment.

BACKGROUND: Medication incidents (MIs) causing harm to patients have far-reaching consequences for patients, pharmacists, public health, business practice, and governance policy. Medication Incident Reporting and Learning Systems (MIRLS) have been implemented to mitigate such incidents and promote continuous quality improvement in community pharmacies in Canada. They aim to collect and analyze MIs for the implementation of incident preventive strategies to increase safety in community pharmacy practice. However, this goal remains inhibited owing to the persistent barriers that pharmacies face when using these systems. OBJECTIVE: This study aims to investigate the harms caused by medication incidents and technological barriers to reporting and identify opportunities to incorporate persuasive design strategies in MIRLS to motivate reporting. METHODS: We conducted 2 scoping reviews to provide insights on the relationship between medication errors and patient harm and the information system-based barriers militating against reporting. Seven databases were searched in each scoping review, including PubMed, Public Health Database, ProQuest, Scopus, ACM Library, Global Health, and Google Scholar. Next, we analyzed one of the most widely used MIRLS in Canada using the Persuasive System Design (PSD) taxonomy-a framework for analyzing, designing, and evaluating persuasive systems. This framework applies behavioral theories from social psychology in the design of technology-based systems to motivate behavior change. Independent assessors familiar with MIRLS reported the degree of persuasion built into the system using the 4 categories of PSD strategies: primary task, dialogue, social, and credibility support. RESULTS: Overall, 17 articles were included in the first scoping review, and 1 article was included in the second scoping review. In the first review, significant or serious harm was the most frequent harm (11/17, 65%), followed by death or fatal harm (7/17, 41%). In the second review, the authors found that iterative design could improve the usability of an MIRLS; however, data security and validation of reports remained an issue to be addressed. Regarding the MIRLS that we assessed, participants considered most of the primary task, dialogue, and credibility support strategies in the PSD taxonomy as important and useful; however, they were not comfortable with some of the social strategies such as cooperation. We found that the assessed system supported a number of persuasive strategies from the PSD taxonomy; however, we identified additional strategies such as tunneling, simulation, suggestion, praise, reward, reminder, authority, and verifiability that could further enhance the perceived persuasiveness and value of the system. CONCLUSIONS: MIRLS, equipped with persuasive features, can become powerful motivational tools to promote safer medication practices in community pharmacies. They have the potential to highlight the value of MI reporting and increase the readiness of pharmacists to report incidents. The proposed persuasive design guidelines can help system developers and community pharmacy managers realize more effective MIRLS.

Using Smart Home Technologies to Promote Physical Activity Among the General and Aging Populations: Scoping Review.

BACKGROUND: Health-monitoring smart homes are becoming popular, with experts arguing that 9-to-5 health care services might soon become a thing of the past. However, no review has explored the landscape of smart home technologies that aim to promote physical activity and independent living among a wide range of age groups. OBJECTIVE: This review aims to map published studies on smart home technologies aimed at promoting physical activity among the general and aging populations to unveil the state of the art, its potential, and the research gaps and opportunities. METHODS: Articles were retrieved from 6 databases (PubMed, CINAHL, Scopus, IEEE Xplore, ACM Library, and Web of Science). The criteria for inclusion were that the articles must be user studies that dealt with smart home or Active Assisted Living technologies and physical activity, were written in English, and were published in peer-reviewed journals. In total, 3 researchers independently and collaboratively assessed the eligibility of the retrieved articles and elicited the relevant data and findings using tables and charts. RESULTS: This review synthesized 20 articles that met the inclusion criteria, 70% (14/20) of which were conducted between 2018 and 2020. Three-quarters of the studies (15/20, 75%) were conducted in Western countries, with the United States accounting for 25% (5/20). Activities of daily living were the most studied (9/20, 45%), followed by physical activity (6/20, 30%), therapeutic exercise (4/20, 20%), and bodyweight exercise (1/20, 5%). K-nearest neighbor and naïve Bayes classifier were the most used machine learning algorithms for activity recognition, with at least 10% (2/20) of the studies using either algorithm. Ambient and wearable technologies were equally studied (8/20, 40% each), followed by robots (3/20, 15%). Activity recognition was the most common goal of the evaluated smart home technologies, with 55% (11/20) of the studies reporting it, followed by activity monitoring (7/20, 35%). Most studies (8/20, 40%) were conducted in a laboratory setting. Moreover, 25% (5/20) and 10% (2/20) were conducted in a home and hospital setting, respectively. Finally, 75% (15/20) had a positive outcome, 15% (3/20) had a mixed outcome, and 10% (2/20) had an indeterminate outcome. CONCLUSIONS: Our results suggest that smart home technologies, especially digital personal assistants, coaches, and robots, are effective in promoting physical activity among the young population. Although only few studies were identified among the older population, smart home technologies hold bright prospects in assisting and aiding older people to age in place and function independently, especially in Western countries, where there are shortages of long-term care workers. Hence, there is a need to do more work (eg, cross-cultural studies and randomized controlled trials) among the growing aging population on the effectiveness and acceptance of smart home technologies that aim to promote physical activity.

Using serious mobile games to improve health literacy in rural Sub-Saharan Africa: A literature review.

The African gaming industry is beginning to flourish as a result of a rise in the availability of inexpensive phones and the number of mobile phone subscribers. It has enabled the development and implementation of mobile serious games to promote healthy behavior change in rural communities. This paper examines the use of mobile serious games in healthcare education, with a particular focus on those designed to increase health literacy in rural Africa. Identifying and addressing the design challenges and issues faced by people living in rural African communities through the use of persuasive mobile games can promote behavior change among these underserved communities. We used PubMed, Scopus, Google Scholar and manual search to identify relevant studies published from 2011 to July 2021. The literature review highlights how the identified challenges affect the implementation of persuasive strategies, suggests design solutions for overcoming them, and discusses how persuasive games can be tailored to suit the target rural African populations. Some of the identified challenges are technical in nature (e.g., access to electricity and internet connectivity), while others are not (e.g., language diversity and low literacy). As the number of serious games for healthcare education and awareness continues to increase, it is essential for the successful implementation of inclusive mobile health technologies in rural Africa to identify and address the specific challenges faced by underserved populations such as rural African communities.

Factors Influencing the Adoption of Contact Tracing Applications: Systematic Review and Recommendations.

Background: The emergence of new variants of COVID-19 causing breakthrough infections and the endemic potential of the coronavirus are an indication that digital contact tracing apps (CTAs) may continue to be useful for the long haul. However, the uptake of these apps in many countries around the world has been low due to several factors militating against their adoption and usage. Objective: In this systematic review, we set out to uncover the key factors that facilitate or militate against the adoption of CTAs, which researchers, designers and other stakeholders should focus on in future iterations to increase their adoption and effectiveness in curbing the spread of COVID-19. Data Sources: Seven databases, including PubMed, CINAHL, Scopus, Web of Service, IEEE Xplore, ACM Digital Library, and Google Scholar, were searched between October 30 and January 31, 2020. A total of 777 articles were retrieved from the databases, with 13 of them included in the systematic review after screening. Study Eligibility Criteria Participants and Intervention: The criteria for including articles in the systematic review were that they could be user studies from any country around the world, must be peer-reviewed, written in English, and focused on the perception and adoption of COVID-19 contact tracing and/or exposure notification apps. Other criteria included user study design could be quantitative, qualitative, or mixed, and must have been conducted during the COVID-19 pandemic, which began in the early part of 2020. Study Appraisal and Synthesis Methods: Three researchers searched seven databases (three by the first author, and two each by the second and third authors) and stored the retrieved articles in a collaborative Mendeley reference management system online. After the removal of duplicates, each researcher independently screened one third of the articles based on title/abstract. Thereafter, all three researchers collectively screened articles that were in the borderline prior to undergoing a full-text review. Then, each of the three researchers conducted a full-text review of one-third of the eligible articles to decide the final articles to be included in the systematic review. Next, all three researchers went through the full text of each borderline article to determine their appropriateness and relevance. Finally, each researcher extracted the required data from one-third of the included articles into a collaborative Google spreadsheet and the first author utilized the data to write the review. Results: This review identified 13 relevant articles, which found 56 factors that may positively or negatively impact the adoption of CTAs. The identified factors were thematically grouped into ten categories: privacy and trust, app utility, facilitating conditions, social-cognitive factors, ethical concerns, perceived technology threats, perceived health threats, technology familiarity, persuasive design, and socio-demographic factors. Of the 56 factors, privacy concern turned out to be the most frequent factor of CTA adoption (12/13), followed by perceived benefit (7/13), perceived trust (6/13), and perceived data security risk (6/13). In the structural equation models presented by the authors of the included articles, a subset of the 56 elicited factors (e.g., perceived benefit and privacy concern) explains 16 to 77% of the variance of users' intention to download, install, or use CTAs to curb the spread of COVID-19. Potential adoption rates of CTA range from 19% (in Australia) to 75% (in France, Italy, Germany, United Kingdom, and United States). Moreover, actual adoption rates range from 37% (in Australia) to 50% (in Germany). Finally, most of the studies were carried out in Europe (66.7%), followed by North America (13.3%), and Australia, Asia, and South America (6.7% each). Conclusion: The results suggest that future CTA iterations should give priority to privacy protection through minimal data collection and transparency, improving contact tracing benefits (personal and social), and fostering trust through laudable gestures such as delegating contact tracing to public health authorities, making source code publicly available and stating who will access user data, when, how, and what it will be used for. Moreover, the results suggest that data security and tailored persuasive design, involving reward, self-monitoring, and social-location monitoring features, have the potential of improving CTA adoption. Hence, in addition to addressing issues relating to utility, privacy, trust, and data security, we recommend the integration of persuasive features into future designs of CTAs to improve their motivational appeal, adoption, and the user experience. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021259080 PROSPERO, identifier CRD42021259080.

The Effect of Persuasive Design on the Adoption of Exposure Notification Apps: Quantitative Study Based on COVID Alert.

BACKGROUND: The adoption of contact tracing apps worldwide has been low. Although considerable research has been conducted on technology acceptance, little has been done to show the benefit of incorporating persuasive principles. OBJECTIVE: This research aimed to investigate the effect of persuasive features in the COVID Alert app, created by Health Canada, by focusing on the no-exposure status, exposure status, and diagnosis report interfaces. METHODS: We conducted a study among 181 Canadian residents, including 65 adopters and 116 nonadopters. This study was based on screenshots of the 3 interfaces, of which each comprised a persuasive design and a control design. The persuasive versions of the first two interfaces supported self-monitoring (of exposure levels), and that of the third interface supported social learning (about how many other users have reported their diagnosis). The 6 screenshots were randomly assigned to 6 groups of participants to provide feedback on perceived persuasiveness and adoption willingness. RESULTS: A multivariate repeated-measure ANOVA showed that there is an interaction among interface, app design, and adoption status regarding the perceived persuasiveness of the interfaces. This resulted in a 2-way ANOVA for each interface. For the no-exposure interface, there was an interaction between adoption status and app design. Among adopters, there was no significant difference P=.31 between the persuasive design (mean 5.36, SD 1.63) and the control design (mean 5.87, SD 1.20). However, among nonadopters, there was an effect of app design (P<.001), with participants being more motivated by the persuasive design (mean 5.37, SD 1.30) than by the control design (mean 4.57, SD 1.19). For the exposure interface, adoption status had a main effect (P<.001), with adopters (mean 5.91, SD 1.01) being more motivated by the designs than nonadopters (mean 4.96, SD 1.43). For the diagnosis report interface, there was an interaction between adoption status and app design. Among nonadopters, there was no significant difference P=.99 between the persuasive design (mean 4.61, SD 1.84) and the control design (mean 4.77, SD 1.21). However, among adopters, there was an effect of app design (P=.006), with participants being more likely to report their diagnosis using the persuasive design (mean 6.00, SD 0.97) than using the control design (mean 5.03, SD 1.22). Finally, with regard to willingness to download the app, pairwise comparisons showed that nonadopters were more likely to adopt the app after viewing the persuasive version of the no-exposure interface (13/21, 62% said yes) and the diagnosis report interface (12/17, 71% said yes) than after viewing the control versions (3/17, 18% and 7/16, 44%, respectively, said yes). CONCLUSIONS: Exposure notification apps are more likely to be effective if equipped with persuasive features. Incorporating self-monitoring into the no-exposure status interface and social learning into the diagnosis report interface can increase adoption by >30%.

COVID Alert: Factors Influencing the Adoption of Exposure Notification Apps Among Canadian Residents.

The continued emergence of new variants of COVID-19 such as the Delta and Omicron variants, which can cause breakthrough infections, indicates that contact tracing and exposure notification apps (ENAs) will continue to be useful for the long haul. However, there is limited work to uncover the strongest factors that influence their adoption. Using Canada's "COVID Alert" as a case study, we conducted an empirical, technology-acceptance study to investigate the key factors that account for users' intention to use ENAs and the moderating effect of important human and design factors. Our path model analysis shows that four factors significantly influence the adoption of COVID Alert among Canadian residents: perceived risk, perceived usefulness, perceived trust, and perceived compatibility. The overall model explains over 60% of intention to use, with type of design, use case (functional interface), and adoption status moderating the strength of the relationships between the four factors and intention to use. We discuss these findings and make recommendations for the design of future ENAs.

Designing Better Exposure Notification Apps: The Role of Persuasive Design.

BACKGROUND: Digital contact tracing apps have been deployed worldwide to limit the spread of COVID-19 during this pandemic and to facilitate the lifting of public health restrictions. However, due to privacy-, trust-, and design-related issues, the apps are yet to be widely adopted. This calls for an intervention to enable a critical mass of users to adopt them. OBJECTIVE: The aim of this paper is to provide guidelines to design contact tracing apps as persuasive technologies to make them more appealing and effective. METHODS: We identified the limitations of the current contact tracing apps on the market using the Government of Canada's official exposure notification app (COVID Alert) as a case study. Particularly, we identified three interfaces in the COVID Alert app where the design can be improved. The interfaces include the no exposure status interface, exposure interface, and diagnosis report interface. We propose persuasive technology design guidelines to make them more motivational and effective in eliciting the desired behavior change. RESULTS: Apart from trust and privacy concerns, we identified the minimalist and nonmotivational design of exposure notification apps as the key design-related factors that contribute to the current low uptake. We proposed persuasive strategies such as self-monitoring of daily contacts and exposure time to make the no exposure and exposure interfaces visually appealing and motivational. Moreover, we proposed social learning, praise, and reward to increase the diagnosis report interface's effectiveness. CONCLUSIONS: We demonstrated that exposure notification apps can be designed as persuasive technologies by incorporating key persuasive features, which have the potential to improve uptake, use, COVID-19 diagnosis reporting, and compliance with social distancing guidelines.

Factors Influencing the Adoption of Contact Tracing Applications: Protocol for a Systematic Review.

BACKGROUND: Following the onset of the COVID-19 pandemic, digital contact tracing apps have become prevalent worldwide in a coordinated effort to curb the spread of COVID-19. However, their uptake has been low and slow due to privacy concerns, the lack of trust and motivational affordances, and their minimalist design. OBJECTIVE: The objective of this article is to present a protocol for a systematic review of the main factors, including facilitators and barriers, that influence the adoption of contact tracing apps. METHODS: We searched seven databases, namely, Scopus, CINAHL, PubMed (MEDLINE), IEEE Xplore Digital Library, Association for Computing Machinery (ACM) Digital Library, Web of Science, and Google Scholar, for relevant publications between October 30, 2020, and January 31, 2021. Three authors were involved in removing duplicates, screening, and selection of relevant articles according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-analysis Protocols) guidelines. RESULTS: Altogether, we retrieved 777 articles from the seven databases. As of May 14, 2021, we have completed the screening process and arrived at 13 eligible articles to be included in the systematic review. We hope to elicit, summarize, and report the main findings in the systematic review article by the end of August 2021. We expect to uncover facilitators and barriers related to app utility, data security, ease of use, and persuasive design that are deemed important to adoption of contact tracing apps. CONCLUSIONS: The findings of the systematic review will help researchers to uncover the gaps in the adoption of contact tracing apps, and decision makers and designers to focus on the principal adoption factors necessary to create better and more effective contact tracing apps. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28961.

E-Commerce Shopping Motivation and the Influence of Persuasive Strategies.

Persuasive strategies are used to influence the behavior or attitude of people without coercion and are commonly used in online systems such as e-commerce systems. However, in order to make persuasive strategies more effective, research suggests that they should be tailored to groups of similar individuals. Research in the traits that are effective in tailoring or personalizing persuasive strategies is an ongoing research area. In the present study, we propose the use of shoppers' online shopping motivation in tailoring six commonly used influence strategies: scarcity, authority, consensus, liking, reciprocity, and commitment. We aim to identify how these influence strategies can be tailored or personalized to e-commerce shoppers based on the online consumers' motivation when shopping. To achieve this, a research model was developed using Partial Least Squares-Structural Equation Modeling (PLS-SEM) and tested by conducting a study of 226 online shoppers. The result of our structural model suggests that persuasive strategies can influence e-commerce shoppers in various ways depending on the shopping motivation of the shopper. Balanced buyers-the shoppers who typically plan their shopping ahead and are influenced by the desire to search for information online-have the strongest influence on commitment strategy and have insignificant effects on the other strategies. Convenience shoppers-those motivated to shop online because of convenience-have the strongest influence on scarcity, while store-oriented shoppers-those who are motivated by the need for social interaction and immediate possession of goods-have the strongest influence on consensus. Variety seekers-consumers who are motivated to shop online because of the opportunity to search through a variety of products and brands, on the other hand, have the strongest influence on authority.

Investigation of persuasive system design predictors of competitive behavior in fitness application: A mixed-method approach.

Fitness applications aimed at behavior change are becoming increasingly popular due to the global prevalence of sedentary lifestyles and physical inactivity, causing countless non-communicable diseases. Competition is one of the most common persuasive strategies employed in such applications to motivate users to engage in physical activity in a social context. However, there is limited research on the persuasive system design predictors of users' susceptibility to competition as a persuasive strategy for motivating behavior change in a social context. To bridge this gap, we designed storyboards illustrating four of the commonly employed persuasive strategies (reward, social learning, social comparison, and competition) in fitness applications and asked potential users to evaluate their perceived persuasiveness. The result of our path analysis showed that, overall, users' susceptibilities to social comparison (ßT = 0.48, p < 0.001), reward (ßT = 0.42, p < 0.001), and social learning (ßT = 0.29, p < 0.01) predicted their susceptibility to competition, with our model accounting for 41% of its variance. Social comparison partially mediated the relationship between reward and competition, while social learning partially mediated the relationship between social comparison and competition. Comparatively, the relationship between reward and social learning was stronger for females than for males, whereas the relationship between reward and competition was stronger for males than for females. Overall, our findings underscore the compatibility of all four persuasive strategies in a one-size-fits-all fitness application. We discuss our findings, drawing insight from the comments provided by participants.

Socially-driven persuasive health intervention design: Competition, social comparison, and cooperation.

Persuasive technologies are tools for motivating behaviour change using persuasive strategies. socially-driven persuasive technologies employ three common socially-oriented persuasive strategies in many health domains: competition, social comparison, and cooperation. Research has shown the possibilities for socially-driven persuasive interventions to backfire by demotivating behaviour, but we lack knowledge about how the interventions could motivate or demotivate behaviours. To close this gap, we studied 1898 participants, specifically Socially-oriented strategies and their comparative effectiveness in socially-driven persuasive health interventions that motivate healthy behaviour change. The results of a thematic analysis of 278 pages of qualitative data reveal important strengths and weaknesses of the individual socially-oriented strategies that could facilitate or hinder their effectiveness at motivating behaviour change. These include their tendency to simplify behaviours and make them fun, challenge people and make them accountable, give a sense of accomplishment and their tendency to jeopardize user's privacy and relationships, creates unnecessary tension, and reduce self-confidence and self-esteem, and provoke a health disorder and body shaming, respectively. We contribute to the health informatics community by developing 15 design guidelines for operationalizing the strategies in persuasive health intervention to amplify their strengths and overcome their weaknesses.

Social cognitive determinants of exercise behavior in the context of behavior modeling: a mixed method approach.

Research has shown that persuasive technologies aimed at behavior change will be more effective if behavioral determinants are targeted. However, research on the determinants of bodyweight exercise performance in the context of behavior modeling in fitness apps is scarce. To bridge this gap, we conducted an empirical study among 659 participants resident in North America using social cognitive theory as a framework to uncover the determinants of the performance of bodyweight exercise behavior. To contextualize our study, we modeled, in a hypothetical context, two popular bodyweight exercise behaviors - push ups and squats - featured in most fitness apps on the market using a virtual coach (aka behavior model). Our social cognitive model shows that users' perceived self-efficacy (ßT = 0.23, p < 0.001) and perceived social support (ßT = 0.23, p < 0.001) are the strongest determinants of bodyweight exercise behavior, followed by outcome expectation (ßT = 0.11, p < 0.05). However, users' perceived self-regulation (ßT = -0.07, p = n.s.) turns out to be a non-determinant of bodyweight exercise behavior. Comparatively, our model shows that perceived self-efficacy has a stronger direct effect on exercise behavior for men (ß = 0.31, p < 0.001) than for women (ß = 0.10, p = n.s.). In contrast, perceived social support has a stronger direct effect on exercise behavior for women (ß = 0.15, p < 0.05) than for men (ß = -0.01, p = n.s.). Based on these findings and qualitative analysis of participants' comments, we provide a set of guidelines for the design of persuasive technologies for promoting regular exercise behavior.

Tracking feels oppressive and 'punishy': Exploring the costs and benefits of self-monitoring for health and wellness.

Self-monitoring is the cornerstone of many health and wellness persuasive interventions. However, applications designed to promote health and wellness that use this strategy have recorded varying degrees of success. In this study, we investigated why the self-monitoring strategy might work in some contexts and fail in others. We conducted a series of large-scale studies, with a total of 1768 participants, to explore the strengths and weaknesses of the self-monitoring strategy. Our results uncover important strengths and weaknesses that could facilitate or hinder the effectiveness of self-monitoring to promote the health and wellness of its users. The strengths include its tendency to reveal problem behaviours, provide real and concrete information, foster reflection, make people accept responsibility, create awareness and raise users' consciousness about their health and wellness. Some of the weaknesses include its tendency to provoke health disorder, be tedious and boring. We contribute to the digital health community by offering design guidelines for operationalising self-monitoring to overcome its weaknesses and amplify its strengths.

Developing Culturally Relevant Design Guidelines for Encouraging Physical Activity: a Social Cognitive Theory Perspective.

The prevalence of physical inactivity and non-communicable diseases is on the rise worldwide. This calls for a systematic approach in addressing the problem, which is almost becoming a global epidemic. Research has shown that theory-driven interventions are more likely to be effective than uninformed interventions. However, research on the determinants of physical activity and the moderating effect of culture is scarce. To bridge this gap, we conducted a large-scale comparative study of the determinants of physical activity among 633 participants from individualist and collectivist cultures. Using the Social Cognitive Theory, a widely applied behavioral theory in health interventions, we modeled the determinants of physical activity for each culture and mapped them to implementable strategies in the application domain. Our structural equation model shows that, in the individualist culture, Self-Efficacy (ßT = 0.55, p < 0.001) and Self-Regulation (ßT = 0.33, p < 0.001) are the strongest determinants of Physical Activity. However, in the collectivist culture, Social Support (ßT = 0.42, p < 0.001) and Outcome Expectation (ßT = 0.11, p < 0.01) are the strongest determinants of Physical Activity. We discussed these findings, mapped the respective behavioral determinants to the corresponding persuasive strategies in the health domain and provided a set of general design guidelines for tailoring the strategies to the respective cultures.