Foundational knowledge - Contemporary Behavior Change Theories

1. Introduction

Contemporary theories emerged once with the development of mHealth apps towards more interactive and adaptative functions that required more than just the components of traditional behavior theories presented above (Salwen-Deremer et al., 2019). Fogg Behavior Model, Internet Intervention Model (RIIM), and Persuasive Systems Design (PSD) model are some promising behavior change models that showed good results with mHealth apps (Salwen-Deremer et al., 2019).

2. Fogg Behavior Model

Fogg Behavior Model is based on three dimensions that converge to prompt behavior change: motivation, abilities and prompts (Fogg, 2021).

1. Motivation refers to structures that facilitate behavior change, such as sensation (pleasure vs pain), anticipation (hope vs fear), and belonging (social acceptance vs rejection) (Fogg, 2021).
2. Abilities refer to both the person’s skills and resources and the difficulty of the behavior. It is dependent upon time, money, physical effort, brain cycles (how mentally taxing a behavior is), social deviance (how socially acceptable a behavior is), and non-routine (routine behaviors are easier to perform) (Fogg, 2021).
3. Prompts refer to the constructs people need to make the behavior. They should be applied at the right time, such that the person has both motivation and ability present when the prompt occurs (Fogg, 2021).

Source: Fogg, BJ. The Fogg Behavior Model. 2018. Available from: http://www.behaviormodel.org/

Fogg Behavior Model was successfully used for mHealth interventions on dietary change and physical activity (Rabbi et al., 2015), preventing obesity (Militello et al., 2016), cervical screen cancer (Lee et al., 2014), and preventing the spread of COVID-19 (Alrige et al., 2021).

3. Internet Intervention Model (RIIM)

Internet Intervention Model (RIIM) suggests that internet-based interventions are effective if they follow the 9 nonlinear steps of the model, namely:

1. User characteristics refer to the patient, consumer, or research participant who bring their own diverse set of variables or characteristics that cannot be manipulated (e.g., age, gender, cognitive traits) and serve as predictor variables in developing an intervention (Ritterband et al., 2009).
2. Environment refers to multiple factors such as family, friends, employer, the community, which can either offer support or put barriers to adopting the behavior; therefore, it needs to be accounted for when developing an intervention (Ritterband et al., 2009).
3. Website refers to the program or application through which treatment is delivered and has eight main areas that need to be taken into account when developing the intervention: appearance, behavioral prescriptions, burdens, content, delivery, message, participation (Ritterband et al., 2009).
4. Website use refers to the actual utilization of the intervention. The other steps of the model highly influence it; therefore, special attention needs to be given to them when developing the intervention (Ritterband et al., 2009).
5. Support refers to how the person’s feels they receive help to make the change. Support usually impacts adherence, ranging from emails and texts to other prompts (Ritterband et al., 2009).
6. Mechanisms of change are the catalysts of transformation and may take the form of knowledge, information, motivation, attitude, beliefs, skill-building, self-efficacy, cognitive restructuring and self-monitoring (Ritterband et al., 2009).
7. Behavior change is the ultimate variable of change, and it is critical to identify  behaviors that are essential to change to reduce associated symptoms and achieve a positive outcome (Ritterband et al., 2009).
8. Symptom improvement is the goal of most interventions, and it refers to improving the wellbeing of the target group (Ritterband et al., 2009).
9. Treatment maintenance refers to including some form of relapse prevention in the intervention to help users maintain treatment gains (Ritterband et al., 2009).

The main idea that the model states is that “the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics. Website use leads to behavior change and symptom improvement through various mechanisms of change. The improvements are sustained via treatment maintenance” (Ritterband et al., 2009).

Internet Intervention Model (Ritterband et al., 2009)

4. The Persuasive Systems Design (PSD)

The Persuasive Systems Design (PSD) model helps design and evaluate persuasive systems and describes what content and software functions may be found in the final product of an intervention (Oinas-Kukkonen & Harjumaa, 2009). The model suggests that when designing or evaluating persuasive systems, aspects from the following figure should be considered (Oinas-Kukkonen & Harjumaa, 2009).

Postulates behind PSD model (Oinas-Kukkonen & Harjumaa, 2009)

The PSD identifies three main areas of change: (1) forming a behavior or a cognition; (2) altering a behavior or a cognition; and (3) maintaining a behavior or a cognition (Oinas-Kukkonen & Harjumaa, 2009). The PSD model contains four key design features, each with a subset of components that can be used when designing behavior change interventions:

1. Primary task support includes reducing complex behaviors into simpler ones, tunneling experience, tailoring and personalization, self-monitoring, simulation, and rehearsal of the behavior (Oinas-Kukkonen & Harjumaa, 2009).

2. Dialogue support includes positive reinforcement (praise, rewards), reminders and suggestions, the similarity of actions, visual attractiveness (liking), and social role (Oinas-Kukkonen & Harjumaa, 2009).

3. Credibility includes trustworthiness, expertise, credibility, real-world resemblance, authority, verifiability, and third-party endorsements of the action (Oinas-Kukkonen & Harjumaa, 2009).

4. Social support includes social learning, social comparison, normative influence, social facilitation, cooperation, competition, and recognition (Oinas-Kukkonen & Harjumaa, 2009).