Persuasive Technologies for Helping Diabetics Make and Sustain Healthy Eating Behaviours (Thesis Proposal Sample)

Abstract
The development, adoption and appropriation of M-health applications that transform and boost patient self-management have been promising but the outcomes varied and largely atheoretical. M-health applications targeting diabetics have not only been inapplicable and inappropriate to people’s cultures, context and experiences but based on principles of prescription rather than persuasion. In this paper, we seek to fill this gap by developing and evaluating the effectiveness of a pro-diet M-health system for diabetes patients. Study participants will use the M-health application for a 6 month period in an attempt to gain awareness about their diabetes, cultivate self-care skills and improve their healthy eating habits. Drawing upon the persuasive technology theory and upon the pro-change trans-theoretical behavior model, we examine the appropriation of M-health diabetes application for self-management practice related to healthy eating and examine the biomedical outcomes resulting from healthy eating behavior.

PERSUASIVE TECHNOLOGIES FOR HELPING DIABETICS MAKE AND SUSTAIN HEALTHY EATING BEHAVIOURS
Introduction
Diabetes is a progressive chronic condition that is rapidly evolving into epidemic proportions given the high preponderance of Type 2 diabetes globally. According to WHO estimates, diabetes claimed the lives of 1.5 million people in 2012 and afflicted 9% of the adult population aged 18 years and above in 2014 (WHO, 2012; WHO, 2014) . Mathers & Locar (2006, p. 242) predict that the condition will be the 7th root cause of death by 2030.
Diabetes is an autoimmune syndrome of multifactorial etiology characterized by high blood glucose level caused by the malfunction of insulin producing beta cells in the pancreas, resistance to insulin action by the body or disproportionate glucagon secretion (American Diabetes Association, 2011). The disease is a leading cause of cardio-vascular complications, renal failure, retinopathy, nephropathy, neuropathy, and psychological health problems (Diabetes Association, 2011).
In the year 2014, 3.2 million people in Malaysia were living with diabetes and 34, 422 succumbed to diabetes related complication (IDF, 2014). According to IDF (2014) estimates, diabetes costs per person amount to 570 USD yearly. Given the substantial health, economic and human burden of the disease, there is an urgent need to find improved methods of preventing, detecting and treating diabetes.
E-health technologies are presented as enabler’s in diabetes prevention and care. They can facilitate better patient-provider communication; provide persuasive and interactive information tools to boost patient knowledge and self-management and can also strengthen physicians/patient efficiency through evidence based tracking and recording tools.
However, e-health services for diabetes care have been implemented with varied success due to cost implications, poor reception and in apropos design of applications. The overarching objective of this paper is to develop and test a patient-focused pro-diet M-health application for diabetics grounded in principles of persuasive technology and behavior change theories.
Background of the problem
Problem with diabetes management
Diabetes presents pronounced lifestyle disruption and complex mental burdens for patients due to the psychosocial reconditioning of their lives (Whitmore, 2005, p. 225). In order to successfully manage diabetes, the life of a diabetic has to be carefully regulated and nudged by multifarious systems for the rest of their lives. Diabetics have to regularly monitor their blood sugar levels, take multiple daily injections or nasal inhalation, adhere to a strict diet and exercise regime without which their condition would extremely debilitate.
At its core, appropriate diabetes care constitutes a number of multifaceted aspects: insulin management, nutritional therapy, fitness and exercise regimen, weight management, blood pressure control, frequent patient monitoring as well as consistent information and communication dissemination between patients and providers (Chomutare, Fernandez-Luque, Arsenal, & Hartvigsen, 2011).
This well-established and uncompromising treatment plan can take a huge toll on patients psychological and mental wellbeing especially newly diagnosed diabetes patients who have to suddenly overhaul their long-standing routines and deep-seated lifestyle behaviors in order to manage diabetes. Diabetics experience numerous difficulties and dilemmas such as: difficulties comprehending and accepting there condition; financial constraints; fatalism; real or functional analphabetism due to a dearth of relevant information or a maze of confusing and mixed message information; depression and lack of motivation (Vargas-Lombardo et al, 2010)
All these factors can contribute to sub-optimal diabetes self-management which as pointed out by Scovlund and Peyrot (2005) is the root cause of poor diabetes outcomes. Poor nutritional choices, irregular physical activity, and failure to effectively adhere to prescribed treatment regimens have been cited as some of the major factors that account for increased morbidity and mortality among this population (Hu, 2011; Helmrich et al, 1991; Delameter, 2006).
Diabetes management approaches should therefore embody multifaceted strategies rooted in psychology, sociology, pathology and behavioral change (Vargas-Lombardo et al, 2010). This paper aims to analyze the effectiveness of emerging m-health diabetes management strategies through the lens of the persuasive technology paradigm and health behavior models.
Problems with M-health diabetes application
Technology can alter the experience and course of diseases: a critical life condition can be deflected into a tractable ‘chronic’ lifelong condition. In the case of diabetes, technology has long been used to subdue the progression of the disease through inventions such as the insulin pumps, insulin pens, smart lenses, smart monitors, bionic pancreas and blood glucose meters (Diana, 2014). These technologies have aimed at increasing hypoglycemic awareness, determining optimal insulin doses, glucose reading, gaining better blood control and lowering HbAIC.
Given the nascency and ubiquitous nature of ICT, emerging communication technologies are quickly finding applications in health education and care, a collusion being termed as E-health. ICT provide innovative ways of accessing, communicating, disseminating and storing information and therefore E-health applications have the potential to provide evidence based records and medical histories of patients, streamline administrative, financial and clinical health systems for work flow efficiency, send real time updates; promote interactive patient-provider communication and serve as health promotion platforms to improve knowledge and behavior change.
While there are various pain points for diabetics that can be addressed through E-health, this paper focuses on examining the effectiveness of M-health applications for enabling more informed and healthy dietary choices.
The mobile revolution is offering newfangled prospects for improving performance and functionality of healthcare services due to their capacity to dispense the right information at the right time and in the right contexts (Langrial, Lehto, Oinas-Kukkonen, Harjumaa, & Karppinen, p. 93, 2012). Mobile platforms offer viable and cost-effective means for providing real-time, on-demand, personalized and asynchronous information exchanges (Kamel Boulos et al, 2014).
Mobile application tools in particular are being widely used by medical providers as drug referencing guides, medical education and teaching tools, and as track and recording tools. Patient centered applications on the other hand provide educational and motivational information to facilitate behavior change; allow for self-diagnosis and management of chronic illness as well as boost telemonitoring, teleradiology, medical imaging, counseling and appointment keeping tasks (Kamel Boulos et al, 2014).
In the diabetes field, SMS services, real time video and images, games, wireless sensors, GPS, smart-phone based diaries, accelerometers and mobile built in application have been employed to examine blood glucose levels; track nutrition and carbohydrates intake; data-sharing and social support as well as promoting proactive diet, exercise and medical adherence norms (Kamel Boulos, 2014).
There were over 20, 000 health apps in popular app store in the year 2014 and over 1000 of this apps are diabetes related (Lee, 2014; Deloitte, 2014). However, 70% of the apps have achieved minimal success with only 30% of the app managing to obtain 90 days user retention (Deloitte, 2014). Studies have also revealed disparities between the implied advantages of M-health apps and real outcomes of mobile health apps. The medical sphere has been particularly skeptical and resistant to the adoption of M-health applications due to the perceived low benefits of these apps (Van Germert-Pignen et al, 2011.)
One of the underlying factors that have contributed to the failure of mobile health apps is the fact that prescription not persuasion is the design focus of most apps (Baumer et al, 2012). Most apps are designed to instruct the user on what to do and what not do to improve health outcomes. Such applications assume that humans act rationally which is further from the truth (Baumer et al, 2012). Underlying emotions, norms, belief, values, culture and lifestyles have a huge influence on healthy behavior. Therefore persuasion and behavior change not just information should be central design principles for mobile health application.
Applications that are not nested in behavior change risk becoming mere paper substitutes with minimal outcomes on patient self-care (Goyal & Caffazzo, 2013). Fogg&rsq...