The eHealth Behavior Management Model uses the theoretical underpinnings of two popular behavior change models, the Transtheoretical Model and the behavioral intent aspect of the Theory of Planned Behavior, as well as the concepts of persuasive communication, to engage Internet users in a pseudocounseling approach. A brief discussion of the key ideas behind these theories will help in understanding the eHealth Behavior Management Model.
The Transtheoretical Model is well known among behavioral scientists and has been widely applied in efforts designed to reduce the occurrence of a multitude of behaviors. This model provides practitioners with an effective way to move individuals toward healthier lifestyles. Change is viewed as a process that occurs over time, rather than an action that must occur as an immediate and direct result of an intervention. The Transtheoretical Model is based on the premise that individuals are in one of five possible stages of change associated with a particular behavior. Precontemplation is the stage in which a person has no interest in changing the behavior. Contemplation is when a person would like to change the behavior someday but is not yet ready. Preparation is when a person is ready to make the change but needs assistance in moving that want into reality. The more active stages include Action and Maintenance. Those in Action have begun the behavior change process. Key to their success is moving the change to Maintenance, where change takes place over time (23
The behavioral intent aspect of the Theory of Planned Behavior is based on the premise that individuals with a defined intent toward change are more likely to engage in change, especially individuals with an attitude that change is necessary. The premise also includes the idea that the closer the change relates to subjective norms, the greater the likelihood that a sense of behavioral control exists (24
). Central to this theory is that beliefs about the behavior, control, and norms influence attitude, subjective norms, and behavioral control. The theory suggests that creating a situation in which intent is high will result in a greater likelihood that an individual will carry through with the intent.
The persuasive communication concepts of response dependence and transactional interaction are key components of the eHealth Behavior Management Model. Transactional communication involves the flow of information between a persuader and a persuadee (25
). It is transactional because at least two parties are involved in both sending and receiving information. To be persuasive, communication must 1) motivate receivers to attend to messages, 2) solicit feedback from users, and 3) elaborate message arguments to move individuals toward change. Current Internet resources typically utilize a one-way communication mode: information exists on a Web page and is accessed by a user. Feedback loops — in which each party involved shares in the roles of sender and receiver — do not usually exist in Internet health communication.
Response-dependent communication controls the flow of the communication process, where responses to inquiries serve as the basis for driving the next round of persuasive messages and inquiries (25
). Response-dependent communication is similar to what may occur between a counselor and a client: questions are asked based on responses to previously asked questions. The response then becomes critical to the direction in which the communication unfolds and can take many forms, such as a question or a persuasive statement, rather than simply an answer to a question.
The eHealth Behavior Management Model creates a persuasive communication environment in which a user and a computer serve as two parties in the communication stream. An underlying algorithm controls the flow of communication that results from transactions between the two parties (). The staging algorithm developed for the eHealth Behavior Management Model was developed specifically for this model and is based on approaches previously used in numerous interventions using the Transtheoretical Model, but it is yet to undergo a comprehensive validation study. The initial Web page in the algorithm consists of a persuasive statement about the issue followed by an opening question for the user. The user has the option of selecting a response, which is typically "yes," "no," "not really," or "sometimes," by clicking on the appropriate response. Subsequent Web pages in the algorithm contain empowering feedback followed by an additional statement about the issue (persuasive argument) and a subsequent question. The communication that occurs between the user and the computer is transactional in that give and take exists between both parties, and the communication is response-dependent as well in that algorithm paths are followed according to responses and feedback.
Algorithm for eHealth Behavior Management Model.
The transactional, response-dependent communication continues until the user arrives at a specific stage of readiness to change. The breadth of the popularity of the Transtheoretical Model has culminated in numerous uses of staging algorithms for myriad behaviors. A popular approach is to use a serious of yes/no questions to determine current stage and the temporal distance of the behavior, resulting in identification of a specific stage of readiness to change (26
). The questions used in the communication process direct the user toward a specific stage of change (). In essence, the model is acting as a diagnostic tool in determining user stage of readiness to change. At this point, the model directs the user to stage-based information already existing on the Internet. These "end nodes" contain information on the behavioral issue. Ideally, end nodes already exist on the Web. All end nodes must be reviewed and approved by model designers for credibility and appropriateness for stage of change and target population.
End-node assessment for stage of readiness to change as well as processes of change that users typically undertake to move toward more active stages are essential to this model because at this point — within the end node — critical information on the user's need for change exists. A systematic four-step method is used by model designers to identify a pool of potential end nodes: 1) review and selection, based on known association and credibility, of Web sites linked from resources on the behavior issue, such as the American Dietetic Association, the U.S. Department of Agriculture, or university extension services; 2) review of Web pages used in existing literature and other academic sources; 3) solicitation of related end nodes from a panel of expert reviewers; and 4) comprehensive search of the Internet using the leading Internet search engines and techniques.
Potential end nodes are scrutinized using a five-step process once the pool has been established. First, end nodes are reviewed to determine their direct associations with the behavioral issues. Suspect end nodes, including those that violate standards set by the U.S. Department of Health and Human Services Science Panel on Interaction Communication in Health, are eliminated. Second, end nodes are assessed for stage of readiness to change, based on general criteria of the Transtheoretical Model. End nodes that cross numerous stages are eliminated from the pool, unless a mechanism exists within the Web page to direct users to information specific to the stage. Third, potential end nodes are further matched against the specific concepts associated with the behavioral issue. Fourth, potential end nodes are assessed for the 10 processes of change associated with the Transtheoretical Model, ensuring the process of change within the end node is appropriate for both the concept associated with the behavior and the stage of change itself. Finally, end nodes are subjected to an expert panel for review and ranking, if more than one end node exists for a specific behavioral concept. End nodes that meet all five criteria are considered viable options for the eHealth Behavior Management Model.
Also central to the model is the ability to move forward in intent toward change based on the stage-based information contained in the end node. The model allows for recognition of this intent and will adjust users in the communication stream to the next stage of readiness to change, providing users with the opportunity to fortify intent even further (). Users also have the option of exiting from the model after reviewing stage-based end nodes. A feedback loop in the model allows users to provide comments on what continues to hold them back from moving forward in intent toward change; this feedback can provide model designers with direction on end-node selection. In the nutrition education program discussed in this paper, information on the beginning node, the ending node, and the reasons for not progressing further in stage of change are entered onto a certificate of completion, which is then used by agency staff to further counsel clients toward additional resources designed to aid in progress toward an active stage of change.
Intent to change option of the eHealth Behavior Management Model.