Technology and Health: Promoting Attitude and Behavior Change

Song

Part I

Theory and its application for health promotion

Outline

Chapter 1. The use of interactive technologies in health promotion and education: Theorizing potential interaction between health message content and message modality

Chapter 2. Digital embodiment and improving health outcomes: Healthy avatars make for healthy people

Chapter 3. Avatar embodiment experiences to enhance mental health

Chapter 4. Age-sensitive well-being support: Design of interactive technologies that modulate internal—external attentional focus for improved cognitive balance and behavioral effectiveness

Chapter 1

The use of interactive technologies in health promotion and education

Theorizing potential interaction between health message content and message modality

Kai Kuang     Department of Communication Studies, Bloomsburg University of Pennsylvania, Bloomsburg, PA, United States

Abstract

Health communication initiatives delivered via information and communication technologies are getting increasing attention and importance. Extant research has focused on the effectiveness of interactivity on health-related attitudinal and behavioral outcomes, while little attention has been paid to how health message content may interact with health message modality such as interactivity in generating effects. Importantly, not much is known about the psychological processes underlying such interaction effects between the message content and the level of interactivity through which the message is presented. This chapter reviews literature on the effects of interactivity and message content constructs on health-related outcomes, argues that message content needs to be considered in conjunction with message modality (i.e., interactivity), and provides a theoretical framework that seeks to explicate how interactivity may amplify or attenuate the effects of message content on health-related outcomes. Implications and suggestions for future research are discussed.

Keywords

Health promotion; Information and communication technologies; Interactivity; Learning and persuasive outcomes

Technology offers exciting opportunities for health promotion and education. In recent years, Internet-based public health intervention communication initiatives (e.g., e-Health) and mobile-health technology-based interventions (e.g., m-Health) are gaining more attention (e.g., Bennett & Glasgow, 2009; Fotheringham, Owies, Leslie, & Owen, 2000). Health promotion and education delivered via new media, or information and communication technologies (ICTs) in general, could offer highly interactive experience for target audience, with distinctive and innovative technological features on the interface through which health messages are presented (e.g., Kreps & Neuhauser, 2010, 2013; Rafaeli & Ariel, 2007; Strecher, 2007; Strecher, Greenwood, Wang, & Dumont, 1999; Street & Rimal, 1997; Sundar, 2007). Theoretical advancements as well as empirical investigations on computer-, Internet-, and mobile technology–based health communication focus extensively on the construct of interactivity (e.g., Bucy & Tao, 2007; Kim & Stout, 2010; Rafaeli & Ariel, 2007; Sundar, 2007), located at the confluence of mass and interpersonal communication and poised between traditional and innovative media (Rafaeli & Ariel, 2007 , p. 378). Systematic reviews and meta-analyses have been conducted to examine the effectiveness of interactive interventions in health promotion and education initiatives (e.g., Foy et al., 2010; Free et al., 2013; Lustria et al., 2013). These reviews suggest that interactivity in health promotion and education has the potential to improve health outcomes as well as the effectiveness of communication. One goal of this chapter is to synthesize extant research with regard to conceptualizations and operationalizations of interactivity in health communication and review empirical studies that tested the effectiveness of these interactive health interventions.

In addition, research in health communication has theorized and tested the effects of different message content constructs (e.g., susceptibility, severity, self-efficacy, cues to action). Narrative and systematic reviews within different theoretical frameworks have also been conducted. These reviews synthesize the effects of different health messages and appeals on health outcomes and perceived message effectiveness (e.g., fear appeals, Witte & Allen, 2000; the extended parallel process model, Maloney, Lapinski, & Witte, 2011; the health belief model, Carpenter, 2010; the risk information seeking and processing model, Yang, Aloe, & Feeley, 2014). With the increasing popularity of health communication initiatives delivered via interactive technologies, it is important to consider these health message content constructs together with the key feature of interactivity in mediated health communication initiatives. Therefore, another goal of this chapter is to review literature on message content constructs and present an initial theorization of how message content constructs may influence health behaviors and message perceptions together with interactivity. In the following sections, literature on both interactivity and health message effects is reviewed.

Defining interactivity

Conceptualizations and operationalizations of interactivity

As a defining feature of online technologies and a key variable in understanding the uses and effects of media technologies (especially new media), interactivity has distinct conceptualizations adopted by different research traditions (e.g., Heeter, 1989; Jankowski & Hanssen, 1996; Rafaeli, 1988; Sundar, Kalyanaraman, & Brown, 2003; Walther, Pingree, Hawkins, & Buller, 2005). Most of the definitions in the literature focus on an exchange of information, processes of reciprocal communication, responsiveness, and some variation on user control (e.g., Walther et al., 2005). For example, earlier interactivity researchers define interactivity as existing when users have the potential to be not only the recipients but also the sources of content; in addition, interactivity relates to the interaction that takes place on a medium (December, 1996). This perspective focuses on processes of reciprocal influence between the users and the medium (Pavlik, 1996).

In a similar vein, interactivity can refer to the proportion of user contribution to existing activity on the site; that is, the ratio of user activity to system activity (Paisley, 1983, p. 155). ¹  Heeter (1989) introduces six dimensions of media interactivity, including available choice, user effort, the extent to which the medium is responsive, system use monitoring, contributing information, and whether the medium facilitates interpersonal communication. These six dimensions are closely related to the technological aspects of the medium that enable interactivity. For example, a medium that allows users to leave comments and engage in live chat will be considered having a higher level of interactivity compared to a medium that only allows user to receive information (but not contribute information). Following this conceptualization, the corresponding operationalization of interactivity focuses on the technological aspects of the interactive features on the medium, including the number of functional characteristics such as hyperlinks and e-mail links, comment boxes, feedback forms, and chat rooms (e.g., Kiousis, 2002; Massey & Levy, 1999).

Further problematizing the construct of interactivity from a dichotomous state to a more sophisticated conceptualization, Steuer (1992) defines interactivity as related to how much a medium allows users to modify the form and content of a mediated environment in real time (p. 84). Other conceptualizations highlighted how much users maintain control in the process of communication. For example, scholars like Jensen (1998) and Newman (1991) define interactivity as the extent of user control afforded by the medium, specifically, the potential ability to let the user exert an influence on the content and/or form of the mediated communication (Jensen, 1998, p. 201). William, Rice, and Rogers (1988) define interactivity as the extent to which users maintain control and exchange roles in the process of communication. In Bucy and Tao's (2007) mediated moderation model of interactivity, the scholars extend the focus on the processes of reciprocal communication and exchange of information between the users and the medium or between users through technology. They conceptualize interactivity as technological attributes that enable such reciprocity and exchange and afford interaction. The focus on reciprocity in the conceptualization of interactivity is commonly adopted in research on online health communities. For example, in their investigation of interactivity in health support group websites, Harrison, Barlowa, and Williams (2007) conceptualize interactivity as the elements of the site that allow users to participate in online communities and interact with other users. In fact, interactivity has been identified as one of the key attributes of online support groups (Walther et al., 2005).

While some conceptualizations of interactivity focus on the nature of information exchange and the reciprocal processes, others highlight user's perceptions and actions of the medium (McMillan & Hwang, 2002; Sundar et al., 2003; Tremayne & Dunwoody, 2001). Indeed, some researchers would argue how users utilize the functions presented on a medium is more important that the media features themselves in determining interactivity (e.g., Kayany, Worting, & Forrest, 1996; McMillan & Hwang, 2002; Walther, 1994). For example, Newhagen, Cordes, and Levy (1995) conducted a content analysis of 650 Internet mail messages sent to NBC Nightly News about the impact of new technologies. Their findings suggest that the levels of interactivity of a medium are dependent upon people's perceptions. McMillan and Hwang (2002) argue that most of interactivity literature focuses on the communication processes or functions of a medium, while not much attention is paid to interactivity as a perception; that is, the extent to which users actually perceive the communication environment as interactive. In explicating an operational definition of interactivity that is perception based, they define interactivity as related to three overlapping constructs, including direction of communication, user control, and time (McMillan & Hwang, 2002). Interactive media allow users to engage in interpersonal, two-way communication, provide a range of navigational and content tools to allow for user control, and enable users to navigate through information in an efficient manner.

More recent conceptualizations of interactivity incorporate some combination of the different aspects reviewed above (e.g., Kiousis, 2002; Liu & Shrum, 2002; Sundar, 2007). For example, Sundar (2007) explicates the concept of interactivity and suggests that three forms exist: medium (modality) interactivity, message interactivity, and source interactivity. Medium or modality interactivity refers to the features, tools, or modalities available on the medium that allows users to access and interact with information. This is also referred to as the functional view, which focuses on the breadth of functions offered by a medium such as sliders and zoom features that allow the users to have more control over the interface compared to a webpage that does not have these functions (Xu & Sundar, 2014). In addition, message interactivity is related to the nature of information exchange that takes place between the user and the medium and between the users. Specifically, this kind of interactivity is operationalized by organizing the information on the interface into different layers through the use of hyperlinks and navigation tools (Sundar, Jia, Waddell, & Huang, 2015). This is also labeled as the contingency view. Last but not least, source interactivity refers to the extent to which users serve as the sources of information in mediated environments, as they have control over the flow and nature of content on the interface.

In sum, conceptualizations and operationalizations of interactivity in the literature focus on distinct aspects of the construct. Some emphasize the nature of information exchange, reciprocal communication process, mutual discourse (i.e., two-way communication), and user control (e.g., Jensen, 1998; Newman, 1991), while others highlight functions and features on the interface (e.g., Massey & Levy, 1999; Sundar, 2007). Some approaches propose that user perception of interactivity is a crucial part of the construct, in addition to message and modality interactivity (e.g., Kiousis, 2002; McMillan & Hwang, 2002). Based on these existing conceptualizations of interactivity in literature, interactivity can be summarized as given below.

Interactivity refers to (a) the degree to which users maintain control by making decisions among the available choices they have on the interface; (b) the extent to which users can both consume and contribute information on the interface by using navigational and content tools, accepting and processing responses from the medium, and modifying the form and content of the medium; (c) the extent to which reciprocal influence and mutual dependence are demonstrated in the process of interaction between users and the medium, and between users; and (d) the degree to which users themselves perceive the mediated communication environment as interactive.

Effects of interactivity

Although defined with distinct conceptual and operational foci, researchers have consistently detected significant main effects of interactive intervention in the literature, especially within health communication research and practice. This section reviews literature on the effects of interactivity on information seeking, learning, persuasion, and health outcomes within areas related to health communication.

Several theoretical frameworks in the interactivity literature have explicated different ways through which interactivity can generate effects. Sundar's theory of interactive media effects (TIME; Sundar, 2007; Sundar et al., 2015), for instance, proposes that the three forms of interactivity may function in related but distinctive ways, all of which will lead to higher levels of user engagement. Specifically, modality interactivity (i.e., functional view) would lead to greater engagement by enhancing users' perceptual bandwidth (Reeves & Nass, 2000; Sundar, 2007). In other words, the interactive functions can help individuals expand and envision the range of things they can do with the medium (i.e., perceptual bandwidth). Message interactivity (i.e., contingency view) leads to greater engagement and elaboration of the information by enhancing the interdependency (contingency) in the message exchange process. In comparison, source interactivity can positively influence engagement by enhancing users' ability to contribute content (e.g., customize and create content as a source).

Bucy and Tao (2007) further problematize the processes through which interactivity generates effects. In their mediated moderation model of interactivity, the scholars identify the roles of technological attributes of a medium, user perceptions about interactivity, and individual differences such as Internet self-efficacy in influencing the outcomes of interactivity. Their model proposes that interactive attributes of an interface would influence affect, behavior, and cognition through user perception. This process, however, may be moderated by individual differences such as Internet self-efficacy (e.g., Eastin & LaRose, 2000). For example, users with varying levels of Internet self-efficacy, defined as the belief in one's capabilities to organize and execute courses of Internet actions required to produce given attainments (Eastin & LaRose, 2000, p. 611), may evaluate interactive technological attributes in different ways. Those with higher Internet self-efficacy may favor interactive technologies, while those with lower Internet self-efficacy avoid them (Bucy & Tao,