Persuasive technology for health and wellness: State-of-the-art and emerging trends

Abstract

The evolving field of persuasive and behavior change technology is increasingly targeted at influencing behavior in the area of health and wellness. This paper provides an empirical review of 16 years (85 papers) of literature on persuasive technology for health and wellness to: (1.) answer important questions regarding the effectiveness of persuasive technology for health and wellness, (2.) summarize and highlight trends in the technology design, research methods, motivational strategies, theories, and health behaviors targeted by research to date, (3.) uncover pitfalls of existing persuasive technological interventions for health and wellness, and (4.) suggest directions for future research.

Keywords

behavior change systems behavior theories gamification health and wellness health interventions health technology healthy behavior motivational strategies persuasive strategies persuasive technology

Introduction

Persuasive Technology (PT) are interactive systems designed to aid and motivate people to adopt behaviors that are beneficial to them and their community while avoiding harmful ones. The use of PT, aimed at bringing about desirable change by shaping and reinforcing behavior and/or attitude is growing in virtually all areas of health and wellness. Over the past decade, several PT have been developed targeted at impacting one or more aspects of health and wellness. These technologies can broadly be classified into two main category: PT for health promotion and prevention and PT for disease management.^1,2 PT for health promotion and prevention are targeted at behaviors undertaken by individuals for the purposes of preventing illness, detecting early illness symptoms, and maintaining general wellbeing.³ Examples include being physical activity,^4–6 healthy eating,^7–9 smoking cessation,^10,11 avoiding risky sexual behavior and unwanted pregnancy,^12,13 and dental health.^14–16 PT for disease management help patients improve health-related self-management skills such as teaching them how to manage certain illnesses, helping them comply and adhere to treatment directives.¹⁷ Each of these health behavior domains has attracted considerable attention.

There is an increasing interest and investments in developing and using technology to promote health and wellness by various stakeholders including health and wellness researchers and practitioners, technology designers, and public health and government agencies. Therefore, it is necessary to conduct an empirical review to reevaluate and uncover important trends, best practices, gaps, and opportunities for improvement. In addition, research on this topic is fragmented, using many different approaches, methods and concepts. A literature review can help bring these disparate sources together.

Thus, in this paper, we present an empirical review of 16-years (from 2000 to 2015) of PT studies across various health and wellness domains with the aim of: (1.) answering important questions regarding the effectiveness of persuasive technology for health and wellness; (2.) highlighting and summarizing emerging trends in the technological intervention design, research method, target health behavior, use of motivational strategies and behavior theories – which is important in guiding and setting roadmap for subsequent research agenda; (3.) uncovering pitfalls of existing PT interventions for health; and finally, (4.) suggesting directions for future research. This review serves as a reference for future research in this area, providing a comprehensive overview that will be a useful starting point for anyone interested in an overview of persuasive technology for health and wellness by systematically analyzing and categorizing the scattered research effort in this area under useful headings and highlighting the merging trends.

Materials and methods

As our goal is to systematically analyze persuasive technology in the health domain, we employed quantitative content analysis, a technique which enables comparison, contrast, and categorization of data according to different themes and concepts.¹⁸ This entails collecting data in a rigorous way, paying special attention to the objectivity of the results.

For our literature search, we used the Elsevier Scopus database as our first data source with the search terms “Persuasive Health Technology”, “Persuasive Technology and Health”, “Behavior Change Technology and Health” “Persuasive Technology”, “Technology and Health Interventions”. Scopus is the largest abstract and citation database of peer-reviewed literature.¹⁹ We also searched PubMed, EBSCOHost, Springer, the ACM Digital Library, IEEE Xplore, and Google Scholar with the same search term. This ensures good coverage of technological health interventions across various fields including Human-Computer Interaction (HCI), medical and health informatics, health information systems, and other related research field. Finally, we scanned through the reference lists of the included studies to find further potentially relevant studies. The search resulted in 1842 unique titles, of which 544 articles were deemed relevant following a title examination. After the abstracts of each article were reviewed, a total of 85 articles that were published from 2000 to 2015 are included in this analysis. We included only articles that discussed the design and evaluation of new PT for health and wellness or an evaluation of existing PT for health and wellness and are published in English. We also excluded papers describing the design and development of PT for health without an evaluation. The study identification process is as summarized in Figure 1.

Figure 1.

Included study identification process.

Analysis and coding scheme

In the second stage of the review, we coded the articles. To achieve this, we iteratively developed a coding sheet for analyzing PT, see Table 1. Next, we went through each of the articles and classified their data using the coding sheet. The coding sheet included the following parts (see Table 1):

Table 1.

Persuasive technology classification and analysis coding scheme.

S/N	Identification	Name, author(s), year, publication venue
1	Targeted (Health) Domain	Physical activity, Eating, smoking, etc.
2	Technology	Web, mobile, games, desktop applications, etc.
3	Duration of Evaluation	Hours, Days, Weeks, Months, and Years.
4	Behavior Theories	Theories Employed in the PT design or evaluation
5	Motivational Strategies	Motivational affordance employed in PT design
6	Evaluation Method	Quantitative, Qualitative, and Mixed.
7	Targeted Age group	Children, Adults, Elderly, etc.
8	Number of Participants	Number of participants involved in the evaluation.
9	Study Country	Country where the study was conducted.
10	Targeted behavioral or psychological outcome	Behavior, Attitude, Adherence, etc.
11	Findings/Results	Whether successful or not.

Results

The analysis of existing PT for health and wellness revealed some interesting insights and trends. Below we present our findings under various categories including: evaluation outcome, employed technology platform, persuasive and motivational strategies, behavior theories, targeted behavior domain, theory, strategy, and outcome mapping. The detailed summary of all the reviewed studies is presented in the Appendix.

Persuasive health technology by year and country

As shown in Figure 2, a relatively large proportion of empirical studies of PT for health and wellness are published after 2005 compared to before 2005. However, there was a big jump starting in 2005, and after that it has been relatively stable, despite some year to year fluctuation. It is important to highlight that although the year 2015 seems to have the least number of studies since 2005 (Figure 2), it is probably because the study was completed halfway through 2015, with many of the publications for the year still pending.

Figure 2.

Persuasive technology for health and wellness trend by year.

As shown in Figure 3, the studies were conducted in 21 different countries with the USA leading the list with a total of 38% of all the studies. USA is followed by the Netherlands with 19%. Taiwan is in the third place with a total of 6% and Finland and Japan are the fifth place, having 5% each of all the studies.

Figure 3.

Persuasive technology for health and wellness trend by study country.

Evaluation outcome: does persuasive health technology work? Effectiveness of persuasive health technology

Figure 4, summarizes the reported results from the evaluation of the PT for health and wellness reviewed in this paper. Of the 85 reviewed studies, 64 (75%) reported fully positive outcome from using the PT to impact specified health behavior. Fourteen studies (17%) reported results partially positive – a combination of positive with negative or no effect results. Only 7 (8%) of all the studies were unsuccessful at achieving their intended persuasion objective – finding negative results, no positive results, or no results at all.²⁰ The results of the effectiveness of PT for health and wellness are detailed in Table 2.

Figure 4.

Summary results of the effectiveness of persuasive technology.

Table 2.

Detailed results of the effectiveness of persuasive technology.

Outcome	Study	Total	% overall
Positive	[5]–[9], [12]–[17], [21]–[70]	64	75%
Partially Positive	[10], [11], [71]–[82]	14	17%
Negative or others	[15], [83]–[88]	7	8%

Technology platforms for persuasive technology

Figure 5 summarizes the major technology platforms employed by PT for health and wellness designers. The most frequently employed technology platforms emerged to be mobile and handheld devices with a total of 27 (28%). It is followed by games with 16 (17%). Games category included all the studies that delivered their PT interventions in the form of games irrespective of whether the game is mobile-based, web, or runs on a stand-alone desktop. In addition, persuasive implementations on the web and social networking sites are common among the studies reviewed. Ambient and public display is the least frequently employed platform with 5(5%).

Figure 5.

Persuasive technology platforms.

Persuasive strategies and motivational affordance employed

The reviewed studies employed several persuasive strategies and motivational affordances to bring about the intended persuasion outcomes. Table 3 shows the prevalent motivational affordance and persuasion outcome. Tracking and monitoring is the most frequently employed strategy (with a total of 34 studies), followed by feedback (28). It is important to note that approximately 80% of the reviewed studies employed more than one motivational strategy (see the Appendix) and are categorized accordingly. Some of the studies did not specify their strategy.

Table 3.

Persuasive strategies/motivational affordances by Persuasion Outcome.

Motivational strategies/affordances	Studies with positive result	Studies with partially positive result	Studies with negative result or others	Total
Tracking and monitoring	[4], [6], [8], [14], [21], [22], [27], [29], [33]–[38], [46]–[50], [55], [56], [58], [60], [62], [67], [70], [89]	[10], [73], [75], [79]	[15], [85], [86]	34
Audio, Visual and Textual Feedback	[4], [6], [7], [9], [14], [16], [27], [29], [30], [37], [43], [46], [48], [50], [65]–[67], [69]	[11], [71], [72]	[15], [83]–[85], [87], [88]	28
Social support, sharing, and comparison	[22], [24], [25], [27], [30], [41], [32], [35], [44], [45], [46], [48], [53], [65], [66], [4], [21]	[75]	[84], [88]	23
Persuasive messages, reminder, and alert	[22], [30], [34], [35], [37], [42], [49], [53], [55], [58], [60], [63]	[72]–[75], [77]	[86], [87]	19
Reward, points, credits	[6]–[9], [17], [25], [27], [30], [34], [38], [39], [47], [59], [61], [69]	[76]	[15], [86]	17
Goal and Objectives	[4], [6], [9], [22], [25], [46], [47], [57]	[75], [77], [79]	[86]	13
Competition, leaderboards, ranking	[4], [17], [22], [34], [39], [41], [47], [52], [56], [62]		[88]	11
Tailoring, Personalization and customization	[12], [17], [38], [40], [68], [70]	[72]	[86]	8
Praise	[14], [22], [24], [40]	[78]	[83], [86]	7
Cooperation and Collaboration	[4], [32], [47], [52]	[81]		5
Virtual rehearsal and Simulation	[12], [24], [63], [69]			4
Emoticons and persuasive images	[15], [26], [33]			3
Progress	[4], [6]		[87]	3
Positive Reinforcement	[6], [15]	[78]	[87]	3
Negative Reinforcement	[8]	[78]	[87]	3
Suggestions and advice	[5], [14]	[72]		3
Video-based persuasion	[23]			1
Not Specified	[13], [28], [31], [51], [54], [64]	[80], [82]		8

Behavior theories employed

Examining behavior change theories employed reveals that more than half of all the studies reviewed (55%) are not informed by any theory or did not specify the theories that inform their PT intervention design, see Table 4. Even among the studies that specified the theories that informed their design, most of them only mentioned the theories without actually specifying how the theories informed the actual PT intervention design components and/or evaluation. Transtheoretical model of change (TTM) is the most frequently employed theory with a total of 13 (14%) studies. Most of the studies based on theories employed more than one theory or adapted constructs from more than one theory.

Table 4.

Behavior theories employed in persuasive technology design.

Theories	Study	Total
Transtheoretical Model	[4], [6], [8], [9], [11], [25], [27], [30], [33], [57], [64], [72], [89]	13
Goal Setting Theory	[15], [23], [75], [77], [79]	5
Social Conformity Theory	[35], [57], [69]	3
Theory of Reasoned Action	[21], [69]	2
Self Determination Theory	[29], [54]	2
Unified Theory of Acceptance and Use of Technology	[26], [80]	2
Reinforcement Theory	[15], [38]	2
Social Cognitive Theory	[23]	1
Ego Depletion theory	[31]	1
Premack’s principle	[38]	1
Parallel Process Model	[13]	1
Theory of Meaning Behavior	[54]	1
Sexual Health Model	[12]	1
Social Learning Theory	[78]	1
Health Belief Model	[69]	1
Theory of Planned Behavior	[44]	1
Big Five Personality Theory	[80]	1
Knowledge, Attitude, Behavior Model	[9]	1
Cognitive Behavior Therapy	[57]	1
Technology Acceptance Model	[30]	1
Not specified	[5], [7], [10], [16], [17], [22], [24], [28], [32], [34], [36], [37], [39]–[43], [45]–[53], [55], [56], [58]–[63], [65]–[68], [70], [71], [73], [74], [76], [81]–[88]	51

Targeted health behavior domain of persuasive technology by persuasion outcome, motivational strategies, and behavior theories

As can be seen from Figure 5 and Table 5, the PT for health and wellness reviewed in this paper fundamentally focused at imparting eight major health behavior domain, including physical activity, eating, dental health, disease management, smoking and substance use, sexual behavior, general health, and others. “Others” consists of health behaviors that appeared less frequently (in all cases, only one study looked to the behavior) such as sleeping, and depression. Physical activity has attracted the most research interest, making up 38% of all the reviewed studies, followed by healthy eating with a total of 25%.

Table 5.

Targeted Health Domains of Persuasive Technologies by Persuasion Outcome, Motivational Strategies, and Behavior Theories – only frequently employed strategies and theory are reported for domains with many strategies such as physical activity and eating.

Health Domain	Studies with positive result	Studies with partially positive result	Studies with negative result or others	% of all	Motivational Strategies (no. of PTs employing each strategy)	Behavior theories (no. of PTs employing each theory)
Physical Activity	[4]–[6], [21], [22], [25], [27], [29], [32], [38]–[41], [46]–[48], [50], [52], [54], [56], [59], [61], [62], [66]	[73]–[75], [79]	[15], [85], [86], [88]	38%	Tracking and monitoring (19)Social support, sharing, and comparison (17)Competition, leaderboard, ranking (10)Reward, points, credits (10)Goal and Objectives (9)Audio, Visual and Textual Feedback (8)	Transtheoretical Model (4)Goal Setting Theory (3)Theory of Meanings of Behavior (2)Self-determination theory (2)Operant Conditioning (2)
Eating	[7]–[9], [17], [28], [30], [31], [33], [35], [45], [55], [60], [65], [67]–[70], [89]	[78]	[83]	25%	Audio, Visual and Textual Feedback (8)Tracking and monitoring (7)Social support, sharing, and comparison (6)Reward, points, credits (5)	Transtheoretical Model (4)Health belief modelSocial learning theorySocial Cognitive TheoryKnowlegde-Attitide-Behavior Model
Dental Health	[14]–[16], [24]			5%	Audio, Visual and Textual Feedback (3)Tracking and monitoring (2)	Operant Conditioning (2)
Disease Management	[36], [58]	[77], [80]	[84]	6%	Tracking and monitoringGoal and ObjectivesPersuasive messages, reminder, and alert	Goal Setting Theory
Smoking and Substance Abuse		[10], [11], [72]		4%	Social support, sharing, and comparisonGoal and ObjectivesTracking and monitoring	Transtheoretical Model(2)
Sexual behavior (HIV and STD)	[12], [13]			2%	Virtual rehearsal and Simulation	Parallel Process ModelSexual Health Model
General Health	[51], [53]	[82]		4%	Social support, sharing, and comparisonPersuasive messages, reminder, and alert	None
Others	[23], [26], [34], [37], [42]–[44], [49], [57], [63], [64]	[71], [76], [81]	[87]	18%	ProgressPositive and negative ReinforcementSuggestionPraise	Cognitive-Behavior TherapyAcceptance and Commitment TherapyBig Five Personality TheoryTechnology Acceptance ModelPremack’s principleEgo Depletion theoryReinforcement TheoryUnified Theory of Acceptance and Use of TechnologyTheory of Reasoned ActionSocial Conformity Theory

Health behavior domain and persuasion outcome

With respect to the persuasion outcomes, it is difficult to speak specifically to the domain specific effectiveness of PT for health and wellness because of the variability in the number of studies from each domain included in this analysis and other domain-specific factors that could influence the effectiveness of PT including the instantiation and operationalization of the persuasive strategies and the duration of evaluation. However, based on the results from the analyzed studies, PT targeted at smoking and substance abuse related behaviors appear to be the least successful with respect to the effectiveness of PT at promoting the desirable change in the domain. All three studies (100%) on smoking and substance abuse analyzed only reported partially positive results – a combination of positive with negative or no effect results. This is followed by disease management with 60% of all the studies reporting either negative or partially positive results. On the other hand, PT targeting dental health and sexual behaviors seem to be the most successful with respect to the effectiveness of PT at promoting the desirable change in the domain. All the studies related to dental health and sexual behaviors (100%) analyzed reported positive results. For eating related behaviora, 91% of all the studies reported fully positive results while for physical activity, 75% of all the studies reported fully positive results. Similarly, 67% of all the studies related to general health reported fully positive results. Finally, for the “Others” category which consists of health behaviors that appeared less frequently in our study, 73% of all the studies reported fully positive results. Figure 6 presents the comparative effectiveness of PT by targeted health domain.

Figure 6.

Comparative effectiveness of PT by health domain.

Health behavior domain and motivational strategies employed

Some strategies were more frequently applied in one health and wellness domain than others. For example, tracking and monitoring is a common motivational and persuasive strategy in the physical activity and eating domain. As shown in Table 5, column 6, tracking and monitoring was employed 19 times and 7 times by PT targeting physical activity and eating behaviors respectively. Similarly, simulation and rehearsal is a popular strategy in the sexual behavior domain.

On a general note, tracking and monitoring; social support, sharing, and comparison; competition, leaderboard, and ranking; and rewards, points, and credits (listed in decreasing order of frequency) emerged as the top four strategies that are commonly employed by PT interventions in the physical activity domain. Similarly, for eating behavior tracking and monitoring; audio, visual, and textual feedback; and social support, sharing, and comparison (listed in decreasing order of frequency) emerged as the top three strategies. Finally, for dental behavior, audio, visual, and textual feedback followed by tracking and monitoring were the commonly employed strategies.

The variations in the popularity of the strategies across various health and wellness intervention domain may be due to the fact that some strategies are easier to operationalize in one domain than the other. However, there is no clear relationship between the strategies or the number of strategies employed in the PT design and persuasion outcome – PT effectiveness. This is probably due to many possible factors that could mediate the effectiveness of the strategies employed in PT including differences among the target population and the need to tailor the strategies to be appropriate for the target audience. The possible variations in operationalization and instantiations of the strategies is another possible factor.

Health behavior domain and behavior theories employed

Although most analyzed studies are not based on any known behavior theories or did not specify the theories that informed the design, for those that did, some theories seem to be more popular in one health and wellness domain than the other. As can be seen from from Table 5, column 7, theories such as the Transtheoretical model is more prevalent in the smoking and substance abuse, physical activity, and health eating domain. Similarly, goal setting theory is used mostly in physical activity and disease management domain. The variations in the popularity of the theories across various health and wellness intervention domains may be due to the fact that some theories are more suitable for some domain and can be easily operationalized than others. For instance, theories such as Transtheoretical model were developed in the context of smoking cessation. Although, it has since been proven effective for developing interventions targeting other health and wellness domains, it is more popular in the smoking cessation interventions as shown by this study. However, there is no clear relationship between the theory or the number of theories used to inform the PT and the persuasion outcome – PT effectiveness.

Targeted behavioral/psychological outcomes

With respect to the behavioral or psychological outcome targeted, as shown in Table 6, the studies are targeted at change in 12 distinct outcomes. Nearly half of all the studies (44%) are targeted at actual Behavior change (either promoting desirable behaviors or motivating change of undesirable behaviors). Seventeen percent (17%) were targeted at Attitude change and 17% at increasing Motivation, while an additional 7% were categorized as “Other” a category housing all studies that either did not specify the targeted behavioral outcome or included a targeted outcome unrelated to behavior. Most of the studies targeted more than one behavioral outcome and hence assessed the effectiveness of their PT on more than one behavioral outcome. As a result, some studies belong to more than one category in Table 6. The behavioral outcomes were not often measured using standardized instruments; creating or reinventing measurement instruments is a common trend among reviewed studies. Again, some studies that were targeted at actual behavior ended up evaluating the effectiveness of their systems by measuring some mediating psychological outcomes such as Attitude and Motivation because of the long evaluation period needed to establish actual change in behavior.

Table 6.

Behavioral/psychological outcomes targeted by persuasive technology.

Behavioral/Psychological Outcomes	Study	% of 85
Behavior	[4], [6], [7], [11], [12], [15], [17], [21]–[25], [27], [28], [32], [33], [35], [38], [41], [46], [48], [56], [58], [60], [62], [63], [65]–[67], [70]–[76], [79], [81], [83], [86], [88]	44%
Attitude	[5], [9], [10], [13], [17], [26], [30], [59], [65], [68], [76], [78], [84]	17%
Motivation	[6], [31], [37]–[40], [54], [57], [61], [64], [78]	17%
Awareness	[16], [43], [47], [50]–[52], [77], [84]	15%
Self-efficacy	[13], [17], [29], [30], [64], [69], [77], [84]	13%
Adherence and Compliance	[36], [34], [42], [49], [53], [55]	10%
Habit	[7], [8], [48]	5%
Knowledge	[8], [14], [80]	5%
Intention	[17], [69]	4%
Engagement and Acceptance	[32], [45]	4%
Belief and Perception	[10], [44], [89]	4%
Others	[10], [31], [82], [85]	7%

Study methodology used by persuasive technology

Data collection and analysis trend

Table 7 summarizes the methodology employed by the reviewed paper in evaluating their PT for health and wellness. Mixed method emerged as the dominant method. Of all the studies, 46% employed mixed method combining both quantitative and qualitative approaches in their study. This is followed by the quantitative approach, accounting for 39%. The most commonly used approach for collecting quantitative data was questionnaire/survey. A few studies (mostly physical activity motivating PT and games) collected additional quantitative data via logged data of user’s behavior and system usage.^{6,34,45,55–57,62,77,88–90} A fully qualitative approach is the least popular with only 15% of all the studies using the approach. The most frequently used qualitative methods are interviewing, focus-group discussion and observation of participants’ behaviors and PT use.

Table 7.

Study methodologies used by persuasive technology.

Method	Studies with positive outcome	Studies with partially positive outcome	Studies with negative/other outcome	% of all
Quantitative	[5], [12], [13], [15], [21], [22], [24], [28], [29], [35], [41], [42], [44], [45], [48], [49], [51], [52], [54], [59], [64], [65], [67], [69], [70], [89]	[10], [74], [78], [80], [82]	[87]	39%
Qualitative	[7], [14], [33], [38]–[40], [43], [44], [46], [47]	[76]	[85], [86]	15%
Mixed Method	[4], [6], [8], [9], [16], [17], [23], [25]–[27], [30]–[32], [36], [37], [40], [43], [55], [57], [58], [60], [62], [63], [66], [68]	[10], [24], [28], [31], [71], [75], [76]	[15], [83], [84], [88]	46%

Regarding the data analysis methods used in the reviewed studies, frequencies, percentages, and means and standard deviations are the most popular methods. ANOVA, Regression analysis and t-tests are the commonly used as inferential techniques. Content analysis was the most used qualitative data analysis methods.

Duration of evaluation

With respect to how long the PT were evaluated, the duration of evaluation varied substantially, ranging from 15 minutes to 3 years. However, some studies did not report how long their PT evaluation lasted. Only a few studies conducted a longitudinal evaluation of their PT^12,72,84 and the majority of the studies did not conduct a follow up study beyond the initial (feasibility) study. Therefore, it is difficult to establish long-term effects of PT for health and wellness from existing studies.

Study participants and sample size

Similar to the study duration, the sample size (number of participants in the evaluation of the PT) also varies greatly. The sample size ranges from 1 to 16,340 participants, with a mean sample size of 258 participants. However, one study did not report the total number of participants in their evaluation⁶¹ and some studies are conducted in stages with the sample size and composition varying at each stage. In such cases, we report a combined sample size from all stages. Most of the study participants are recruited using a convenience sampling method and were recruited from academic communities or via online forums.

As can be seen from Figure 7, 66% of all the studies are targeted at adults, 16% involved children and teens, only 13% are targeted specifically at elderly people, and 5% of all the studies did not specify the target audience.

Figure 7.

Targeted age demographic.

Discussion

Effectiveness of persuasive technology for health and wellness

Following from the reviewed literature, it can be concluded that persuasive technologies are effective at promoting various health and wellness related behavior with 92% of all the reviewed studies reporting some positive outcome (fully and partially positive) from PT use.

Although the majority of the studies (72%) are targeted at behavior and/or attitude change in line with the original conceptualization of PT by Fogg⁹¹ (technology intended to change attitude and/or behavior), generally, the studies targeted and measured various other behavior-related or psychological outcomes beyond the conventional outcome of behavior and attitude. Similarly, some of the technologies are aimed at reinforcing and strengthening existing behavior (e.g., increase daily step count while others aimed at changing behavior (quitting smoking). This shows that persuasive technology has evolved over the years to encompass various practices that were not in the initial conceptualization.

The relationship between target health behavior domain (persuasion context) and persuasive technology outcome

There seem to be some variations in the effectiveness of the PT across various health and wellness domain. PT targeted at smoking and substance abuse related behaviors appear to be the least successful with respect to their overall effectiveness at promoting the desirable change in the domain. This is followed by PT targeting disease management. On the other hand, PT targeted at dental health; sexual behaviors; eating related behaviors; and physical activity (listed in decreasing order) seem to be the most successful with respect to the effectiveness of PT at promoting the desirable change in the domains. It is important to note that the effectiveness of the PT in various domains could be influenced by many factor including the operationalization of the persuasion strategies and behavior theories, the length and depth of evaluation, and the appropriateness of the PT for the target audience. Therefore, due to this methodological plurality and the heterogeneity of sample sizes and data, we are not able to draw strong conclusions about which persuasion contexts provided the most positive effects.

The relationship between behavior theory and persuasive technology outcome

Although, it is difficult to fully establish that using behavior theory to inform the design of PT influences their effectiveness due to the limited number of study in this review (85), the review results suggest that there may be some relationships. All the studies that are based on known theories but one¹⁵ reported either fully positive or partially positive results. The study,¹⁵ which failed employed an instantiation of negative reinforcement hence confirming that the use of any form of punishment as motivational strategy may backfire. Theories such as TTM and goal setting theory are more prevalent in the literature than others. However, the popularity of the theories vary across the domains. Theories such as TTM is common in the smoking and substance abuse, physical activity, and eating related domains.

The relationship between motivational strategies and persuasive technology outcome

Although several research efforts have been directed toward developing taxonomies for naming and classifying persuasive and motivational strategies,^91,92 there still exist many inconsistencies in both naming and operationalizing strategies in persuasive systems. In some cases, the only way that one could possibly identify the actual motivational strategies employed in the PT is by studying how they work. Again, while some strategies such as monitoring/tracking, feedback, and social support seem to be more frequently used than others, it does not seem that there is a relationship between the strategy employed and the success of the PT. This is probably because of the variations in the instantiation and framing of the strategies. For instance, feedback is often instantiated in different forms, including audio, visual, or text based feedback, in various degrees of granularity, and in one of two valences – positive or negative. This variation in instantiations is likely to impact effectiveness. The choice of how to instantiate and operationalize the strategies are solely based on PT designer’s own discretion. Again, some strategies are more dominant in some health domains than the other. For example, monitoring and tracking strategy is a predominant strategy in physical activity and eating behavior motivating PT than other health wellness domains. Similarly, simulation and rehearse is a popular strategy in the sexual behavior domain.

General limitations and recommendations for future research

Based on the results of this review, we identified specific gaps in the literature and we offer suggestions for improvement and moving the field forward:

The PT literature lacks standardized approaches or tools for evaluating the effectiveness of PT and most existing evaluation approaches are based on subjective data which can be biased. Research into alternative assessment and evaluation techniques would enrich the PT community. In particular, the persuasive community would benefit greatly from research into objective evaluation approaches.

PT studies are limited in terms of effective integration of behavior theories and practice in their design. This is probably because most PT designers often lack the skills needed to translate theoretical determinants of behavior into technology design artefacts. We recommend that future research be focused on developing a comprehensive framework for translating theoretical determinants into technology design components.

Most PT employed more than one strategy in their design (see the appendix), therefore making it difficult to establish whether there is a relationship between the strategies and success of the PT. Research aimed at establishing the interactions between individual strategies and the success of PT either using sophisticated statistical techniques or by examining the effectiveness of the strategies in isolation would be vital to the community and would contribute in advancing the field.

Only a few studies have conducted longitudinal evaluations of the effectiveness of their PT.^12,72,84 We stress the need for research in this direction to establish the long-term effect of PT on health and wellness.

Only a few PT involved the target audience in their design.^30,79 We recommend that PT designers adopt the participatory design approach to enable the involvement of the target group(s) in deciding on the theories, strategies, and particular instantiation that will be suitable for the target audience and behavior.

Finally, there is a need for more PT to target diverse demographies such as older adults and children.

Conclusion

This paper provides a review of the effectiveness and trends of Persuasive Technology (PT) for health and wellness. The review results show that PT is a promising approach for promoting desirable behavior on a broad and heterogeneous range of health and wellness. However, lack of large-scale and longitudinal evaluations makes it impossible to establish the long-term impact of PT at promoting desirable behavior in the area of health and wellness. The review also highlighted PT trends and limitations of existing studies and suggested some improvements and future research direction.

Footnotes

Appendix

Appendix 1.

A comprehensive overview of persuasive technology for health and wellness.

Authors	System/Project Name	Health Domain	Technology	Motivational Strategy	Behavior Theory	Country	Reference
Kim et al. (2008)	BuddyClock	Sleeping	Mobile	Feedback, status sharing	None	USA	[71]
Graham et al. (2006)	QuitCoach	Smoking	Web	Social support, Feedback and Advice	Transtheoretical model	Australia	[11]
Zwinderman et al. (2012)	Phone Row	Physical activity	Mobile game	Competition and leaderboard, feedback, and social comparison via Facebook	None	Netherlands	[88]
Young (2010)	Twitter Me	Physical activity	Combination of web, phone, and pedometer	Tracking and monitoring, sharing, Competition, praise, goal setting, reward, social comparison, persuasive text messaging	None	Netherlands	[22]
VanDeMark et al. (2010)	E-TREAT	Substance abuse	Computer-based application	Tailored persuasive messages, Individualized feedback, personalized coaching and support, suggestion	Transtheoretical model	USA	[72]
Van Leer and Connor (2012)	Mobile video	Voice therapy	Mobile	Video-based persuasion	Goal setting theory, social cognitive theory	USA	[23]
Toscos et al. (2008)	Mobile app.	Physical activity	Mobile	Social support, Persuasive text message, tracking and monitoring, sharing achievements	None	USA	[73]
Salam et al. (2010)	PMLE	Dental anxiety	CD ROM	Virtual Rehearsal, similarity, praise, and social learning	None	Malaysia	[24]
Sakai et al. (2011)	APStair	Physical activity	Publicly displayed screen	Authority, commitment, and consensus	None	Netherlands	[74]
Nakajima and Lehdonvirta (2013)	Persuasive Art	Physical activity	Ambient mirror	Tracking and monitoring, Reward, persuasive visual art, feedback, empathetic expressions	Goal setting theory, reinforcement theory	Japan	[15]
Nakajima and Lehdonvirta (2013)	Virtual Aquarium	Dental hygiene - Tooth brushing	Ambient mirror	Goal and objective, tracking and monitoring, visual feedback, positive reinforcement	Reinforcement theory, information theory	Japan	[15]
Mutsuddi and Connelly (2012)	Text messaging app	Physical activity	Desktop text messaging app	Goal and objective, reward, sharing testimonies	Transtheoretical model	USA	[25]
Munson and Consolvo (2012)	GoalPost and GoalLine	Physical activity	Mobile	Goal and objective, self-monitoring, sharing, reminder	Goal setting theory	USA	[75]
Mintz et al. (2012)	HANDS iProject	Autism	Mobile	Source credibility - expertise and trustworthiness, reward	None	Denmark, Sweden, Hungary, and UK	[76]
Looije et al. (2006)	iCat-personal assistant robot	Diabetes	Robot	Emoticons and visual expressions	Unified theory of acceptance and use of technology	Netherlands	[26]
Lim et al. (2011)	Pediluma	Physical activity	Physical activity tracker	Tracking and monitoring, visual feedback, reward, sharing	Transtheoretical model	USA	[27]
Lee et al. (2011)	Snackbot	Eating	Robot	default	None	USA	[28]
Lee et al. (2011)	Snack ordering site	Eating	Web	Default and Information	None	USA	[28]
Lacroix et al. (2009)	Activity monitor	Physical activity	Wearable device	Tracking and monitoring, visual feedback.	Self-determination	Netherlands	[29]
Kroes and Shahid (2013)	Powerfood	Eating	Mobile	Social Influence, feedback, comparison, reminder, points	Transtheoretical model, technology acceptance model	Netherlands	[30]
Kehr et al. (2012)	Chocolate Machine	Eating	Chocolate machine	Not specified	Ego depletion theory	Germany	[31]
Kaplan et al. (2003)	TLC-Computer-based telecommunication system	Chronic disease management	Computer-based application	Goal and objective, reminder	Goal setting theory	USA	[77]
Jeen et al. (2007)	Self-Diet System	Eating	Web	Source credibility, praise, negative reinforcement, social facilitation	Social learning theory	Korea	[78]
Foster et al. (2010)	Step Matron	Physical activity	Facebook app and pedometer	Competition, comparison	None	UK	[41]
Gasca et al. (2008)	pHealthNet	Eating and physical activity	Pedometer, mobile and web	Social support, collaboration, commitment	None	Mexico	[32]
Fabri et al. (2013)	Cooking Website	Eating	Web	Tracking and monitoring, Persuasive images	Transtheoretical model	UK	[33]
Consolvo et al. (2008)	UbiFit Garden	Physical activity	Mobile and activity sensor	Tracking and monitoring, visual feedback, reward, goal and objective progress display, positive reinforcement	Transtheoretical model	USA	[6]
Grimes et al. (2010)	OrderUp	Eating	Mobile game	Reward	Transtheoretical model	USA	[8]
De Oliveira et al. (2010)	MoviPill	Adherent to prescriptions	Mobile game	Tracking and monitoring, reward and point, reminder, competition	None	Spain	[34]
Chiu et al. (2009)	Playful bottle	Water intake (eating)	Mobile enabled Tracking and game	Tracking and monitoring, reminder, social support	Social conformity theory	Taiwan	[35]
Chang et al. (2008)	Playful toothbrush	Dental Hygiene - Tooth brushing	Game	Tracking and monitoring, visual and audio feedback, suggestion, praise	Teaching-learning theory	Taiwan	[14]
Bhatnagar et al. (2012)	Biometric system	Chronic disease management - tuberculosis	Biometric tracker	Tracking and monitoring	None	India	[36]
Berque et al. (2011)	Typing tracker	Healthy typing - repetitive strain injury	Computer-based application	Tracking and monitoring, reminder, visual and auditory feedback	None	USA	[37]
Berkovsky et al. (2012)	PLAY MATE!	Physical activity	Game	Tracking and monitoring, reward	Reinforcement theory, premack’s principle	Australia	[38]
Arteaga et al. (2010)	Mobile app	Physical activity	Mobile game	Competition and Reward	Theory of planned behavior, theory of meaning of behavior, personality theory	USA	[39]
Pollak et al. (2010)	Time to Eat!	Eating	Mobile game	Reminder, Control, positive and negative feedback	None	USA	[7]
Soler et al. (2009)	Molarcropolis	Dental hygiene - tooth brushing	Mobile game	Visual feedback	None	Greece	[16]
Khaled et al. (2009)	Smoke?	Smoking	Computer game	Tracking and monitoring	None	New Zealand	[10]
Eyck et al. (2006)	Cycling system	Physical activity	Virtual coach	Tailoring and personalization, tunneling, praise	None	Netherlands	[40]
Albaina et al. (2009)	Flowie	Physical activity	Touch-screen, photo frame and pedometer	Tracking and monitoring, commitment and consistency, goal and objective	Goal setting, classic learning theory	Netherlands	[79]
Rosser et al. (2010)	MINTS-II	HIV/STI	Web	Customization, tunneling, simulation	Sexual health model	USA	[12]
Adams et al. (2015)	Mindless plate	Eating	Sensing plate	Tracking and monitoring, Competition and leaderboard, comparison,	None	USA	[89]
Kientz et al. (2010)	MyPyramid Blast Off	Eating and physical activity	Computer game	Praise, visual feedback	None	USA	[83]
Bickmore et al. (2007)	Wrist-rest agent	Wrist rest	PDA-based social agent	Audio alert	None	USA	[42]
Obermair et al. (2008)	perFrame	Healthy posture	Interactive picture frame	Feedback	None	Austria	[43]
Parmar and Keyson (2008)	PHI	Maternal health and menses	Computer-based application	Social cues	Theory of planned behavior	India	[44]
Gasser et al. (2006)	Mobile app	Eating and physical activity	Mobile and web	Social facilitation	None	Switzerland	[45]
Fritz et al. (2014)	Activity sensor	Physical activity	Activity sensing devices	Tracking and monitoring, reward, goal, conditioning, social-sharing	None	USA	[46]
Sohn and Lee (2007)	UP Desk	Physical activity, smoking	PD text messaging	Tracking and monitoring, competition and leaderboard, cooperation, goal and objective, reward	None	Korea	[47]
Looije et al. (2010)	Robotic assistant	Diabetes self-management	Computer-based application	Not specified	Unified theory of acceptance and use of technology, five factor model	Netherlands	[80]
Toscos et al. (2006)	Chick Clique	Physical activity	Mobile and pedometer	Tracking and monitoring, sharing, comparison, positive feedback	None	USA	[48]
Goessens et al. (2006)	SPAIN pilot-study	Patient’s self-management	Computer-based application	Feedback, social support	None	Netherlands	[84]
McCreadie et al. (2006)	Personal Navigation tool	Physical activity	Mobile app	Tracking and monitoring, feedback	None	UK	[85]
Sterns and Mayhorn (2006)	PDA Pillbox	Medication adherence	PDA pillbox	Tracking and monitoring, reminder	None	USA	[49]
Knipscheer et al. (2006)	Persuasive story table	Loneliness and depression	Digital story telling table	Cooperation and collaboration	None	Netherlands	[81]
McCalley and Mertens (2007)	Pet plant	General health	Digital pet plant	Not specified	None	Netherlands	[82]
Chi et al. (2007)	Digital kitchen	Eating	Calorie aware kitchen	Tracking and monitoring, feedback	None	Taiwan	[50]
Golsteijn et al. (2008)	BLB	General well-being.	Persuasive bulbs	Not specified	None	Netherlands	[51]
Fujinami and Riekki (2008)	Ambient Mirror	Physical activity	Ambient mirror display	Competition, cooperation and collaboration	None	Japan	[52]
Harjumaa et al. (2009)	FT60	Physical activity	Heart rate monitor	Tracking and monitoring, personalization, reduction, praise, reward, reminder, credibility, goal and objective	None	Finland	[86]
Munson et al. (2010)	3GT	General well-being.	Social network	Reminder, sharing	None	USA	[53]
Roberto et al. (2007)	Computer-based application	Pregnancy, STD, and HIV prevention	Computer-based application	Not specified	Parallel process model	USA	[13]
Spruijt-Metz et al. (2008)	Get Moving!	Physical activity	Computer-based application	Not specified	Self-determination theory, theory of meanings of behavior	USA	[54]
Tsai et al. (2007)	PmEB mobile	Eating	Mobile app	Tracking and monitoring, reminder	None	USA	[55]
Fujiki et al. (2008)	NEAT-o-Games	Physical activity	Mobile game	Tracking and monitoring, competition	None	USA	[56]
Kaipainen et al. (2010)	GoodLife	Stress management	Web	Goal and objective, Tunneling	Goal setting theory, Transtheoretical model, cognitive behavior theory, acceptance and commitment therapy	Finland	[57]
Chatterjee et al. (2012)	In-home monitor	Diabetes self-management	Environmental and body-wearable sensors	Tracking and monitoring, reminder	None	USA	[58]
Chittaro and Sioni (2012)	LocoSnake game	Physical activity	Mobile game	Reward	None	Italy	[59]
Langrial and Oinas-Kukkonen (2012)	Web app	Eating	Web	Reminder, tracking	None	Finland	[60]
Peeters et al. (2013)	Social Stairs	Physical activity	Intelligent musical staircase	Reward	None	Netherlands	[61]
Burigat and Chittaro (2014)	Mobile app	Earphone use	Mobile app	Reminder, feedback, positive/negative reinforcement, progress	None	Italy	[87]
Chen et al. (2014)	SP-Stretch, Social Persuasion System	Physical activity	Mobile sensing and game	Tracking and monitoring, competition	None	Taiwan	[62]
Clinkenbeard et al. (2014)	Social network app	Physical activity	Social network	Tunneling, reduction, Suggestion	None	USA	[5]
Langrial et al. (2014)	Good Life Compass	Depression	Web	Reminder, rehearsal	None	Finland	[63]
Kopf et al. (2015)	Pakinson’s Disease related videos	Parkinson’s disease	Video	Not specified	Transtheoretical model	USA	[64]
Takeuchi et al. (2015)	Meal-sharing social media application	Eating	Social network	Feedbacks, sharing	None	Japan	[65]
Cornejo et al. (2015)	GuessMyCaption	Active ageing	Ambient casual game	Visual and audio feedbacks, sharing	None	Mexico	[66]
Orji et al. (2013)	LunchTime	Eating	Web	Goal and objective, reward, social influence, feedback	Transtheoretical model, knowledge- attitude-behavior theory	Canada	[9]
Lin et al. (2006)	Fish’n’Steps	Physical activity	Animated virtual fish	Goal and objective, tracking and monitoring, visual feedback, progress, sharing, competition, cooperation	Transtheoretical model	USA	[4]
Orji (2014)	JunkFood Alien	Eating	Phone-based game	Competition and Reward	None	Canada	[17]
Lo et al. (2007)	Playful Tray	Eating	Digital playful tray and games	Tracking and monitoring, visual feedback	None	Taiwan	[67]
Gerber et al. (2009)	Text messaging app	Eating and physical activity	Mobile	Personalization and tailoring	None	USA	[68]
Peng (2009)	RightWay Café	Eating	Computer game	Feedback, points, rehearsal	Theory of reasoned action, social cognitive theory, health belief model	USA	[69]
Kaptein et al. (2012)	Text messaging app	Eating - snacking	Mobile	Tracking and monitoring, liking, consensus, consistency, authority	None	Netherlands	[70]
Khalil and Abdallah (2013)	SET UP	Physical activity	Mobile	Tracking and monitoring, sharing	Theory of reasoned action	United Arab Emirate	[21]

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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