Skip to main content

New Paper on Tailored Messaging for Exercise

wrote recently about a tailored messaging intervention to help people living with HIV manage fatigue, but it was a pretty labor-intensive approach. One of the research projects that I’m working on right now will automate the tailored messages, with a slightly different but related focus on exercise behavior. With modern antiretroviral medication treatments (ART), people living with HIV can expect to live a relatively normal life, but they are at higher than average risk for problems like heart disease and diabetes as they get older. The latest research on HIV shows that people with the virus not only need regular exercise to prevent heart and kidney problems, they need 30 minutes of higher-intensity exercise on most days of the week. That’s more exercise than most Americans without HIV manage to achieve. 

In a new article, just published in the Journal of the Association of Nurses in AIDS Care, my colleagues and I describe the intervention that we’re testing to help people with HIV be more active. The first part of the intervention is an exercise group that meets for 16 weeks at the campus health center, providing personal-training support as well as group interactions to help people develop their exercise habits. The tailored-messaging component comes in after the intensive group phase is finished, and is designed to help people maintain their exercise habit over time. In addition to the tailored messages, people in our study will receive individual calls from a coach who will use motivational interviewing strategies to support them.

As I have written elsewhere, the things that help us develop a new healthy habit are often different from the things that help us to maintain that habit for the long term. We start doing something new because it’s important to us, but we are most likely to keep doing it when it is easy. The tailored messages, therefore, focus on various barriers that might get in the way of exercising. When we brainstormed possible barriers with our experienced research team, and also asked focus groups that included people living with HIV, we came up with a list of barriers that probably sounds pretty familiar: things like being tired, bad weather, conflicting priorities, or not feeling well that day. In fact, none of the barriers that our team identified had anything specifically to do with HIV! The resulting tailored messages, therefore, might end up being useful to anyone seeking to maintain an exercise habit.

After developing a list of barriers, we brainstormed ideas to help people overcome each of them. In keeping with Two Minds Theory, we used six basic principles of behavior change, targeting both the Intuitive and the Narrative minds:

1.    Training the Intuitive mind through practice,

2.    “Tricking” the Intuitive mind into a different response by modifying environmental conditions and stimuli,

3.    Engaging the Intuitive mind in creative problem-solving to generate ideas that the Narrative mind can then sift through,

4.    Practicing mindfulness strategies that delay the Intuitive response and give the Narrative mind more time to engage,

5.    Using the Narrative mind’s capacity for social imagination to create new incentives and enlist others’ aid, or

6.    Offering reframing ideas that give the Narrative mind different ways of thinking about the problem.

We developed multiple messages using each of these principles, relying on the team’s collective wisdom and experiences. Team members contributed advice, web links, videos, self-help tools, and inspirational quotes. We found that all of these could be linked to one of the six behavior-change principles, although of course I have never claimed those six to be an exhaustive list. (Prochaska originally listed 10 processes of change, for example, and Susan Michie has 16, so there is almost certainly more work to be done in this area). Sometimes a message for one barrier could be adapted to also be useful for people who are experiencing a different barrier (e.g., exercising with a friend might help to alleviate boredom, and also serve as a reminder for people who forget). Other times a message was only applicable to one specific barrier to exercise (e.g., weather, where we had to further differentiate between advice for hot weather, advice for cold weather, advice for when air quality was poor, etc.).

Once we had an initial draft – over 170 messages, each linked to one of 12 barriers – we sent the messages themselves to two different advisory groups to review. The groups again included experts on physical activity research as well as people living with HIV. We asked whether any of the messages struck them wrong, whether any should be edited, and whether they had other suggestions. A few messages were dropped at this stage, a few were added, and a number were edited based on feedback from the advisory groups.

Finally it was time to program the messages into a computer algorithm. For this stage we used a web-based database design program called Caspio, which I had experience using in other research. In principle, any web-enabled relational database would work. We created a survey that asked people about their barriers to exercise, using validated scales to measure things like pain, mood, and fatigue. Then I created some formulas that compared scores on the various scales and identified the person’s top barrier for that day. There were also categories for “no barriers today” and for a control group that we intend to send only supportive, non-tailored messages. Finally, we programmed each message possibility into the system. A random-number generator was used to select from the pool of messages available to address each barrier, so that the participant essentially selects the topic of the message based on their survey responses, but the computer selects the specific message. This was considered important because boredom and repetition were cited as the most important obstacles among participants in a previous study of tailored messaging that I conducted.

Before releasing the tailored messaging tool to actual patients in our study, seven team members tried it out ourselves. This led to some additional changes – a few more messages dropped or edited, but more importantly a shortening of the survey tool. We hid the validated survey items until a person said they actually had a particular concern, which shortened the overall length of the daily survey to just a few questions. We added an extra screen where people could see feedback every day on a graph of their active minutes (at this point self-reported; ideally in a future iteration the data would come from sensor devices). We added a behavior-change coach’s picture along with their contact information. And we removed some explanatory text in order to get to the point – the actual tailored message – more quickly. In this more technical design phase of the project, we focused on usefulness of the system in terms of doing what it was designed to do, and also on ease of use for the end user, because that type of consideration is likely to play an important role in whether or not the tool actually gets used.

You can generate a test message from our system here, or enroll to receive daily messages here (don’t worry: they’re 100% free and you’ll have a way to cancel at any time).

Something that the system doesn’t currently do is to adjust its message content based on users’ demographic characteristics or psychological states, other than the main barrier identified for that day. In my last tailored-messaging study I did that kind of intensive “sculpting” of messages, with word choice and grammatical nuances that were carefully curated in response to a participant’s daily survey responses. In general, people didn’t notice the effort! They got the gist, the take-home message, but they didn’t pay much attention to how it was delivered. So this time around we are letting a random-number generator make those choices. We will still collect data on specific message characteristics, however – for instance, which of the six behavior-change strategies was used. And we will ask people to rate which messages had the most utility. This could lead to future iterations of the algorithm in which more carefully tailored messages can be created by the computer, matching content to individuals based on additional characteristics that we identify from the data as we go along.

Psychological tailoring of health-promotion messages is still pretty wide-open territory for research, and I’m excited to see what we find in this new study. Watch this space for updates once we have some data to report!

Comments

Popular posts from this blog

Why Does Psychotherapy Work? Look to the Intuitive Mind for Answers

  Jerome Frank's 1961 book Persuasion and Healing  popularized the idea of "common factors" that explain the benefits of psychotherapy, building on ideas that were first articulated by Saul Rosenzweig in 1936 and again by Sol Garfield in 1957. Frank's book emphasized the importance of (a) the therapeutic relationship, (b) the therapist's ability to explain the client's problems, (c) the client's expectation of change, and (d) the use of healing rituals. Later theorists emphasized other factors like feedback and empathy that are sub-components of the therapeutic relationship, and that can be clearly differentiated from specific behavior-change techniques like cognitive restructuring or behavioral reinforcement . Additional aspects of therapy that are sometimes identified as common factors include the opportunity to confront difficult past experiences, the opportunity for a "corrective emotional experience" with the therapist, and the chance t

Ethical Improvement in the New Year

  Just after the first of the year is prime time for efforts to change our behavior, whether that's joining a gym, a "dry January" break from alcohol, or going on a diet. (See my previous post about New Year's resolutions for more health behavior examples). This year I'd like to consider ethical resolutions -- ways in which we try to change our behavior or upgrade our character to live more in line with our values.  Improving ethical behavior has been historically seen as the work of philosophers, or the church. But more recent psychological approaches have tried to explain morality using some of the same theories that are commonly used to understand health behaviors based on Narrative constructs like self-efficacy, intentions, and beliefs. Gerd Gigerenzer suggests that an economic model of " satisficing " might explain moral behavior based on limited information and the desire to achieve good-enough rather than optimal results. Others have used simula

Year in Review: 2023

Here’s my annual look back at the topics that captured my attention in 2023. Over the past year I taught several undergraduate mental health classes, which is not my usual gig, although it does fit with my clinical training. The Two Minds Blog took a turn away from health psychology as a result, and veered toward traditional mental health topics instead. I had posts on   mania   and   depression .  I wrote about   loneliness   as a risk for health problems, as well as   hopefulness   as a form of stress inoculation. I wrote about the “ common factors ” in psychotherapy, which help to improve people’s mental health by way of the intuitive mind (I was particularly happy with that one). I also shared findings from a recent study where my colleagues and I implemented a   burnout prevention   program for nursing students, and another new paper that looked at the incidence of mental and physical health problems among   back country search and rescue workers . Mental health has received more