University of Amsterdam
Master Strategic Marketing Management Thesis January 2016
The Role of a Self-Service Technology in Health Care for the
Continuation of Behavioral Change
An Explorative Qualitative Study
Ference Smit
10684611
31 January 2016
Supervisor
Frank Slisser
1 Statement of originality
This document is written by Student Ference Smit who declares to take full responsibility for the contents of this document.
I declare that the text and the work presented in this document are original and that no sources other than those mentioned in the text and its references have been used in creating it.
The Faculty of Economics and Business is responsible solely for the supervision of completion of the work, not for the contents.
2 Contents
1. Introduction………. Page 4 - 9 2. Literature review………. Page 11 - 25
2.1 Self-management programs
2.2 Definitions of SSTs and the concept of behavior 2.3 Two phases of SST usage
2.3.1 Initial drivers for adoption of (new) SSTs 2.3.2 Drivers of continued use of SSTs
2.4 Other factors that influence behavioral changes
3. Methods………... Page 26 - 30 3.1 Research design 3.2 Target group 3.3 Method 3.4 Data collection 3.5 Strengths/ limitations 3.6 Analysis
3.6.1 The analysis strategy 3.6.2 Coding
3.6.3 Process
4. Results………. Page 31 - 52 4.1 The results of the 10 factors based on the literature
4.2 The results of the new factors mentioned by respondents
5. Discussion………... Page 53 - 71 5.1 Discussion on the 10 factors based on the literature
5.2 Discussion on the new factors mentioned by respondents 5.3 In summary the most striking and or deviating factors found with and without the use of a SST
6. Conclusion……… ……….. Page 72 - 75 6.1 Conclusion 6.2 Limitations 6.3 Future research Appendix 1……….. Page 76 – 77 Code tree Appendix 2……….. Page 78 Results figure - factors based on the literature
3 Appendix 3……….. Page 79
Results figure - new mentioned factors by respondents
Appendix 4……….. Page 80 - 83 Results table - factors based on the literature
Appendix 5……….. Page 85 - 86 Results table - new mentioned factors by respondents
4
1. Introduction
Our world becomes more and more self-service orientated. Self-service technologies (SSTs) are already embedded deeper in our lives than most of us know. It is incredible how many of the services that we use in day-to-day life were first provided by employees and are now transformed into a self-service technology. Instead of employees we are more and more served by machines, e.g., self-check-out of groceries at the supermarket, buy coffee out of machines at the gas station, and on almost every corner there is an Automated Teller Machine (ATM). These are all SSTs According to Meuter et al. (2000) SSTs are technological
interfaces that enable customers to produce a service independent of direct service employee involvement. These technologies are a cost effective way to provide service to customers by reducing the costs of staff, since – as the word self-service implies – customers provide a certain service to him or herself using this technology. Health apps, such as MyFitnessPal, are another good example of this technology. Users of this app determine a goal, such as weight loss, provide their activity level (sitting job, sporting, walking, etc.) and then the app
calculates exactly (by knowing the goal set by the consumer, and how active he/she is) how much he/she can consume in calories to be able to reach the goal that is set. Therefore, a personal real-time nutrition advice is created without the help of a dietician or other service employee involvement. Of course, besides (health) apps, there are many other forms of SSTs in other sectors as well. These include services such as banking by telephone, automated hotel check-outs and services over the Internet, such as Federal Express package tracking and online brokerage services (Meuter et al., 2000). This development in the way service is provided has changed rapidly, especially since the last economic crisis changed the world economy. According to Shende (2015) the SST market is expected to reach $31.75 billion, globally by 2020. This market is primarily driven by the enterprises' need to provide more
5 convenient services to the customers, and at the same time optimizing the cost of such
services. Furthermore, Shende states that enterprises operating in sectors such as retail, health care, food and beverage, and banking would be the key demand facilitators. The potential growth in these sectors to develop more advanced SSTs is truly immense. This thesis will focus on the role of the SST in the health care industry. The health care industry interests me in particular because I work in a medical center as a physiotherapist and a marketing
coordinator. All around me I see developments and changes in the way care has been served, the use of technology and the internet is creating new possibilities, which might lead to services that are now done by medical staff that are taken over by SSTs. But care in general is changing enormously, and it has to because the demand is also changing. In The Netherlands, the average life expectancy is increasing (Centraal Bureau voor de Statistiek, n.d.), and the costs of health care are rising (CBS Gezondheid en Zorg in Cijfers 2014, n.d.). A good solution to this problem is to let technology play a bigger role in slow spiraling medical costs (Intille, 2004). Of course, much more should be taken into account when tackling the costs of the Dutch health care system. However, this topic is way too broad to investigate for this thesis. In order to find out what role an SST can play in the health care industry and in providing health care, this thesis will focus on a certain segment in health care, namely the cardiac rehabilitation. It is known that 1 in 4 people of the Dutch population dies because of cardiovascular diseases, meaning that every day more than 100 people die in The Netherlands because of heart and/or vascular diseases (Hartstichting cijfers, n.d.). A report from the
inspection for health care in The Netherlands indicates that the number of people that follow a Cardiac Rehabilitation Program is increasing every year (Inspectie voor de Gezonheidszorg, 2013), which is a good sign because, besides the physical rehabilitation and the increase of labor reintegration, it will also decrease the level of anxiety and depression that follow often after a heart disease is diagnosed (De Rijk et al., 2011). Unfortunately, the number of patients
6 who relapse within 6 months into old habits and unhealthy behavior after cardiac
rehabilitation is more than half (up to 60%) (Moore et al., 1998; Brubaker et al., 2000; Willich et al., 2001). But what is meant by ‘behavior’? According to the business dictionary (n.d.), behavior is a response of an individual or group to an action, environment, person or stimulus. Because of unhealthy behavior and lifestyles people are increasing their risks of cardiovascular diseases (Hartstichting risicofactoren, n.d.). These people risk the chance that the incident (or a related one) will occur again. Such a relapse is very costly. Not only death is at stake (Hartstichting cijfers, n.d.), but a relapse costs a lot of money as well. Think of all the medical costs that have to be made again. These costs can be saved when the chance of relapse is minimalized and a healthier behavior gets a more permanent character. In that way, behavior becomes part of a lifestyle.
According to Pearson et al. (2007), improved behavior is expected to lead to better disease control which should, in turn, lead to better patient outcomes and reduced utilization of health care services, particularly preventable emergency room visits and hospitalizations, and
ultimately to reduced costs. A Self-Management Program (SMP) offers these (chronic) patients a program that reflects a dual purpose: one, to educate people and thereby increase their knowledge, and two, to coach people to change their behavior. More and more literature is testing and supporting SMP’s as a good support for rehabilitation care (Lorig et al., 1999; Pearson et al., 2007; Huber et al., 2011; Máxima Medisch Centrum, n.d.). These support programs create behavioral changes, but not all cardiac rehabilitation programs make use of these support programs. Furthermore, it is difficult for cardiac rehabilitators to persevere this change in behavior as up to 60% relapse (Moore et al., 1998; Brubaker et al., 2000; Willich, 2001). It is also costly because this way of providing cardiac rehabilitation involves a lot of medical staff (and related costs). Added to this, the chance of a permanent behavioral change is not that high (up to 40%) (Moore et al., 1998; Brubaker et al., 2000; Willich, 2001).
7 Because of these high chances of relapse, it is interesting to examine what role SSTs can play in health care.
The demand for self-service machines and automated devices, wireless communication, remote management and technology advancements largely impacts the self-service
technology market, for which, according to Shende (2015), enterprises operating in sectors such as health care would be the key facilitators. To examine what role an SST can play in the health care and more specific in creating a behavioral change by cardiac rehabilitators, an examination of marketing literature on SSTs will be conducted, focusing on two usage phases: (1) the adoption phase, and (2) the continued use phase. Stimuli (factors) from the SST in the adoption and continued use phase create behavioral changes. The assumption is that these factors could also be important for a behavioral change to be continued. The following factors in the adoption phase of an SST will be examined: high perceived level of control (Hui and Bateson, 1991; Lee and Allaway, 2002; Johnson et al., 2008) and the factor of fun within (or without the use of) SSTs (Dabholkar and Bagozzi, 2002; Laran and
Janiszewski, 2011). The influence on the continued use of an SST after the adoption phase is examined by Wang et al. (2013); only this article has been researching the continued role that an SST can play on (usage) behavior.
Other factors (not related to the literature of SSTs) will be discussed to see if they might lead to the continuation of behavior in combination with the use of an SST such as motivation (Miller and Hom, 1990; Lazear, 1996; Kreps, 1997; Ryan and Deci, 2000; Deci et al., 2001), monitoring (Intille, 2004; Mittag et al., 2006), (self-)confidence (Pearson et al., 2007; Wang et al., 2013), problem solving (Pearson et al., 2007), challenge (Radhakrishnan and Ronen, 1999), success (Herzberg, 2003), repeated positive experiences (Zajonc and Markus, 1982), participate in a group or community (Bagozzi & Dholakia, 2006).
8 The Self-Management Program (SMP) is a support program that is focused on the creation of a behavioral change during the rehabilitation process. However, as stated before, the number of people that relapse after rehabilitation is still too high. That is why it is interesting to look at the role that an SST can play in making healthy behavioral changes. Used in health care, an SST has two clear advantages. One, using SSTs may be a cost effective way to provide service because cardiac rehabilitators provide the service (partly) themselves, and two, patients could use the SST as a tool after the rehabilitation to maintain their healthier behavior, which will prevent the rehabilitators from a relapse, which will save money and lives.
In the upcoming research a deeper insight into the literature of the SMP, the adoption and the continued use phase of an SST will be given. The focus is on all the factors that influence behavior. Then several factors known from other literature (than the SST literature) that focused on behavioral changes are analyzed. After my literature review, the differences between the direct effects of the factors on the continuation of a behavioral change will be compared with the moderating effect of the SST use (see Fig. 1). Propositions will follow after every factor is discussed. In-depth interviews were conducted and analyzed by
qualitative research. A figure is made of the most influencing factors to continue a behavioral change positively, negatively and/or neutrally and what the role might be of an SST in this, including the new factors mentioned by the respondents. All propositions formulated will lead to the answer of the following research question: ‘Which factors positively or negatively influence the continuation of a behavioral change and how does this influence on the continuation of a behavioral change differ when a Self-Service Technology is used?’ As a conclusion, practical considerations are given for the use of an SST in the health care
industry, specifically in cardiac rehabilitation. The goal is to lower the number of people that relapse in old habits and bad lifestyles as well as reducing medical costs.
9
2. Literature review
In this literature review, 10 factors that influence behavior and might be important to
influence the continuation of a behavioral change will be discussed. The factors that influence behavior come from various sources: Hui and Bateson (1991), Lee and Allaway (2002) and Johnson et al. (2008) describe the role of high perceived level of control in behavioral changes. The importance of using fun in SST was found by Dabholkar and Bagozzi (2002), and fun in diet programs (Laran and Janiszewski, 2011), while the influence of motivation on the continuation of behavior is stated by Miller and Hom (1990), Lazear (1996), Kreps (1997), Ryan and Deci (2000) and Deci et al. (2001). Intille (2004) and Mittag et al. (2006) described what influence monitoring can have on the continuation of behavior,
self-confidence was found to be important for a behavioral change (Pearson et al., 2007; Wang et al., 2013), and problem solving was essential for the continuation of behavior according to Pearson et al. (2007). Furthermore, it will be discussed what role challenge has on behavior (Radhakrishnan and Ronen, 1999), and also the role of success, as was examined by Herzberg (2003) to be a factor for the continuation of behavior. Zajonc and Markus (1982) found that when people are exposed to repeated positive experiences, their behavior changed and Bagozzi & Dholakia (2006) found what the role can be of participation in a group or
community. A deeper insight into the Self-Management Programs, Self-Service Technologies and other literature focusing on behavioral changes, will clarify the proposed relationship of the factors with the continuation of a behavioral change.
2.1 Self-management programs and cardiac rehabilitation
More and more literature is testing and supporting SMPs as a good support for rehabilitation and the care for chronically ill patients (Lorig et al., 1999; Pearson et al., 2007; Huber et al.,
10 2011; Máxima Medisch Centrum, n.d.). Pearson et al. (2007) explained that the use of an SMP supports the chronically ill in a way that will help them to manage their illnesses as effectively as possible. Through SMPs patients are coached (by health care professionals) and educated to create a behavioral change. Unfortunately the literature shows that a lot of
patients cannot maintain this healthier behavior or lifestyle.
When patients completed a three-month cardiac rehabilitation process in the hospital, 1.5 years later most beneficial effects of what they had learned during the rehabilitation process on risk reduction factors had been lost. For example, they forgot what they had learned or they simply did not act on the lessons learned anymore (Kotseva et al., 2004). As examined by Moore et al. (1998), Brubaker et al. (2000) and Willich (2001) up to 60% of cardiac patients relapse within 6 months after the rehabilitation. This means that somehow people are not succeeding in persevering the behavioral change.
2.2 Definitions of SSTs and the concept of behavior
To examine what role an SST can play in the health care industry and more specific in creating a behavioral change by cardiac rehabilitators, an examination of the literature on SSTs is conducted. According to Meuter et al. (2000), SSTs are technological interfaces that enable customers to produce a service independent of direct service employee involvement. Furthermore, these researchers describe three reasons why companies provide SSTs. First of all, they offer the customer these technologies to provide customer service, i.e., questions regarding accounts, paying of bills, FAQ and delivery tracking (e.g., companies like FedEx and Cisco System's online troubleshooting). Secondly, companies such as Amazon.com and Internet-based travel ticketing services offer these to customers as new ways of transactions, i.e., order online, buy in online shops, and exchange resources. And thirdly, for self-help, i.e.,
11 enabling learning, receive information, train themselves (as in health information web sites, self-help videos and such). This thesis will be mostly examining the field of the third category ‘self-help’. In the end of the rehabilitation the most optimal result is that the patient made a healthy behavioral change and persevered their own health in a self-managing way (whether or not through an SST).
2.3 Two phases of SST usage
In marketing literature a lot of research has been done on factors that influence behavior in relation to the use of an SST (Hui and Bateson, 1991; Dabholkar and Bagozzi, 2002; Lee and Allaway, 2002; Johnson et al., 2008). The factors found in this literature might also be important for the continuation of a behavioral change. Two SST usage phases will now be discussed: the adoption phase and the continued use phase. In these phases of SST usage different stimuli (factors) will come forward that provoke behavior. Then propositions are formulated that explain the influence of these stimuli (factors) on the continuation of a behavioral change, and what the influence of a SST will be on the relationship between these factors and the continuation of a behavioral change.
2.3.1 Initial drivers for adoption of (new) SST's High perceived level of control
High perceived level of control might be important for the continuation of a behavioral change. A few quotes from the literature will follow to exemplify what perceived control is. Perceived control over the service encounter is the amount of influence a customer has over the process or outcome (Hui and Bateson, 1991; Dabholkar, 1996). According to Johnson et al. (2008) SST control is the degree to which customers have the ability to schedule and scale
12 their transactions to meet their specific needs. This increased perceived control increases trust in technology by reducing consumer uncertainty about the outcome. Hui and Bateson (1991) showed that an SST provides consumers with a sense of personal control. Which is important because a high perceived level of control leads to lower perceived risk, higher perceived value, and higher adoption intention (Lee and Allaway, 2002). Johnson et al. (2008) showed furthermore that customers may perceive a sense of control in dealing with an SST when they believe they are the driving forces of the interaction. There is a big difference between when customers feel that they are on the driver's seat and when they feel that they are being overwhelmed by the SST. Regardless of the specific characteristics of the technology, the positive influence of personal control to the adoption decision appears to be universal. The proposition is, therefore, that when the cardiac rehabilitators have a ‘high perceived level of control’ over their behavioral change, it will positively influence the continuation of a behavioral change. And when an SST is used this will have a positive influence on the relationship between high perceived level of control and the continuation of a behavioral change.
Proposition 1a that follows from this is: high perceived level of control positively influences the continuation of a behavioral change.
Proposition 1b: an SST positively influences the relationship between high perceived level of control and the continuation of a behavioral change.
The fun aspect
According to Dabholkar and Bagozzi (2002) marketers should heavily promote the fun aspect of using their technology-based service. High inherent novelty seeking and high self-efficacy customers are easy to promote too because they have a tendency to try new
technology, so these customers would be a perfect fit with this new technology. This tendency to try new technology is even higher when the SST is fun as well. For customers with high
13 self-consciousness, which is defined as a person's view of himself or herself as a social object, with an acute awareness of other people's perspectives about him or her (Mead, 1934;
Fenigstein et al., 1975), and customers with a high need for interaction with a service employee, this fun aspect needs to be emphasized in a subtle way. The idea is to persuade these customers who have from nature a certain form of resistance in onsite encounters (Dabholkar and Bagozzi, 2002). But ‘fun’ seems also be important in dieting programs, like all regulation programs, might be more successful if they were to emphasize the ‘fun’ of regulatory behavior and likewise, framing a dieting program as ongoing (e.g., maintain your weight) as opposed to complete (e.g., reach a target weight of X) should be more effective (Laran and Janiszewski, 2011).
The following proposition is that this factor of ‘fun’ will positively influence consumers to continue the behavioral change, because when the consumers have fun in performing the new behavior (for example exercise), it becomes easier for them to continue doing so. And the fun during the use of an SST will also have a positive influence on the relationship between ‘fun’ and the continuation of a behavioral change.
The following Proposition 2a can be formulated as: fun positively influences the continuation of a behavioral change.
Proposition 2b: an SST positively influences the relationship between fun and the continuation of a behavioral change.
From this SST adoption literature it is proposed that when the consumer perceives a high level of control, or experiences pleasure in carrying out the activity, it will positively influence the continuation of a behavioral change with and without the use of an SST.
14 The drivers that impact behavior that leads to continued use of an SST has only been
researched by Wang et al. (2013). These researchers tested the roles of self-efficacy,
satisfaction and habit in driving continued use of self-service technologies. Wang et al. (2013) found that customers' decisions to continue using an SST are initially rational (self-efficacy), then largely emotion driven (satisfaction) and, finally, habitual (habit). Self-efficacy has a positive impact on customer satisfaction and ease of use. Ease of use increases customer intention to reuse SSTs while decreasing technology anxiety. According to this same article, the use of an SST needs to be without difficulty and deliberate thinking to become automatic and habitual, which requires a high level of self-confidence. As customers accrue experience with the SST, self-confidence is no longer a major issue because users begin appreciating the advantages and benefits of using it. At this point, satisfaction becomes the driving force through habit and intention.
Satisfaction and dissatisfaction
Then what creates the biggest level of satisfaction when using SSTs? Meuter et al. (2000) found what incidents enhanced (dis-)satisfaction when people use SSTs. In this research the focus was on the following SSTs: ATMs, various Internet shopping services, pay-at-the-pump terminals, various automated telephone services, automated hotel check-out, package
tracking, automated car rental pickup and return, and online brokerage services. The most important satisfiers according to this research are that these SSTs: saved time (30%), did its job (21%), was easy to use (16%), and solved an intensified need (11%). The most important dissatisfying incidents that were found were: when technology failed to do its job (43%), a service design problem occurred due to that things were hard to figure out (19%), technology design problems, which means that the technology interface was not clear (17%), and process failure (17%).
15 influence the continued use of an SST. These three concepts coordinate a number of factors that fall under this concept, as shown for satisfaction that contains the factors: saving time, did its job, ease of use and solving an intensified need. It is interesting to examine these three coordinating concepts on the continuation of use with the resulting concepts of this thesis on the continuation of behavioral change.
16
2.4 Other factors that influence behavioral changes
Several factors from other (than the SST) literature are analyzed such as motivation, monitoring, self-confidence, problem solving, challenge, success, repeated positive experience and participation in a group or community. These could also play a role in the continuation of a known behavioral change. A brief insight in these factors and their propositions will follow.
Motivation
A lot of research has been done on intrinsic and extrinsic motivation, factors that are very important for continuing behavior. Ryan and Deci (2000) argued in their article that intrinsic motivation is the self-desire to seek out new things and new challenges, to analyse one's capacity to observe and to gain knowledge. Extrinsic motivation, on the other hand, refers to the performance of an activity in order to attain a desired outcome and it is the opposite of intrinsic motivation. So when people do something because they like to do it, then an intrinsic motivation drives them. When there is a reward or challenge that drives their intentions, then an external motivation is the driver of the action.
Lazear (1996) showed that there is an interaction between the role of norms and economic incentives. Extrinsic incentives can lead to significant increases in worker effort and employer profit, in an employment situation. Furthermore, it is also interesting to examine the
relationship between intrinsic and extrinsic motivation. Kreps (1997) stated that intrinsic motivation is the response of workers to fuzzy but nonetheless extrinsic incentives. Explicit extrinsic incentives that are imposed may fight rather than complement pre-existing
incentives. In other words, extrinsic incentives need to emphasize the voluntary nature of the desired behavior to complement the intrinsic incentives.
17 Miller and Hom (1990) tested what the interactive role is of these incentives on performance after failure and continuing motivation. What they found is that students gave up more
frequently after failure, except when they received rewards or were told the anagram task that they had to perform was very difficult. Especially when we discuss lifestyle changes, failure or not continuing situations may occur, rewards may help people to keep motivated and keep continuing with the task as well as telling them a task is difficult. What form is suitable depends on what type of motivation is required to trigger the patient's intrinsic or extrinsic motivation.
Deci et al. (2001) argue that rewards (and other external events) have two aspects. The informational aspect conveys self-determined competence and thus enhances intrinsic
motivation. In contrast, the controlling aspect prompts an external perceived locus of causality (i.e., low perceived self-determination) and thus undermines intrinsic motivation.
Two interesting rewards are discussed by Deci et al. (2001), namely ‘verbal rewards’ (i.e., positive feedback and so intangible) and ‘tangible rewards’.
Verbal rewards tend to have an enhancing effect on intrinsic motivation. But verbal rewards can also have a negative effect on intrinsic motivation if the interpersonal context within which they are administered is controlling (intention to make students do what the teacher wants them to do) rather than informational (as an affirmation of competence). All tangible rewards significantly undermined intrinsic motivation. For most people the right type of motivation is probably different, for some extrinsic motivations will help them to stay on the right track; for others it will be mostly intrinsic motivation. The proposition is that ‘intrinsic motivation’, ‘extrinsic motivation’, and so ‘motivation’ in general plays an important role for the continuation of a behavioral change with and without the use of an SST.
Proposition 3a: intrinsic motivation positively influences the continuation of a behavioral change.
18 Proposition 3b: an SST positively influences the relationship between intrinsic
motivation and the continuation of a behavioral change.
Proposition 4a: extrinsic motivation positively influences the continuation of a behavioral change.
Proposition 4b: an SST positively influences the relationship between extrinsic motivation and the continuation of a behavioral change.
Proposition 5a: motivation positively influences the continuation of a behavioral change.
Proposition 5b: an SST positively influences the relationship between motivation and the continuation of a behavioral change.
Monitoring
Mittag et al. (2006) described what the effect is of a follow-up intervention rendered by telephone (intervention group) or by written information (control group) on risk reduction. To be specific, risk reduction of behavioral coronary risk factors (like an unhealthy diet, physical inactivity, obesity, too much alcohol, etc.) and enhancing quality of life of in-patient cardiac rehabilitators (a patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay). The patients were contacted monthly by phone for over a year. The researchers found that the program was effective under study conditions (efficacy) yielding lower coronary risk scores in the intervention group compared to the control group. This means that counseling seems a cost-effective method to achieve significant reduction in cardiac risk factors and maintain the outcomes of CR (a continued behavioral change). Intille (2004) also mentioned the example of (mobile) telephones to create healthy behavioral changes. These changes can be realized by sending for instance messages at an appropriate
19 time and place by for instance medical personnel, or by an automated program. Intille
discussed what these messages should contain, for example motivational applications may need to incorporate elements that are fun, humorous, creative, or inspirational to entice users to keep using them. The following propositions are that monitoring (by phone or any device) is an important factor and has a positive influence on the continuation of a behavioral change. One of the theories is that when someone or some technological device will monitor what the consumer is doing, take an eye on him/her, and gives advice, it might give the consumer the idea that they have to continue performing good behavior, because someone/thing is watching them. These methods can give advice, guidance and help them remember to continue the behavior. It is interesting to make a distinction between self-monitoring and (remote)
supervision monitoring by service personnel. The proposition is that ‘supervision monitoring’, ‘self-monitoring’ and ‘monitoring’ in general play an important role for the continuation of a behavioral change with and without the use of an SST.
So thereby the following Proposition 6a is formulated: supervision monitoring positively influences the continuation of a behavioral change.
Proposition 6b: an SST positively influences the relationship between supervision monitoring and the continuation of a behavioral change.
Proposition 7a is formulated: self-monitoring positively influences the continuation of a behavioral change.
Proposition 7b: an SST positively influences the relationship between self-monitoring and the continuation of a behavioral change.
Proposition 8a: monitoring positively influences the continuation of a behavioral change.
20 Proposition 8b: an SST positively influences the relationship between monitoring and the continuation of a behavioral change.
Self-confidence and problem solving
Pearson et al. (2007) explained the use of an SMP to support the chronically ill in a way that it will help them to manage their illnesses as effectively as possible. In their article they state that in 2003, the Institute of Medicine defined self-management support as “the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.” Self-management support programs are expected to reduce costly health crises and improve health outcomes for
chronically ill patients with conditions such as asthma, cardiovascular disease, depression, diabetes, heart failure and migraine headaches. The proposition here is that the factors problem solving and self-confidence both are important for the continuation of a behavioral change. When consumers face a problem during the execution of their new behavior, they need the skills to solve it themselves, otherwise the risk of a relapse is at stake. But their problems can also be solved by others, e.g., medical staff or relatives (external problem solving). It is therefore interesting to make a distinction between self-problem solving skills and external problem solving. Pearson et al. (2007) described that enhancing confidence is an important supportive intervention especially in SMPs. According to Wang et al. (2013) the use of an SST needs to be without difficulty and deliberate thinking to become automatic and habitual, which requires a high level of self-confidence. So the propositions in relation to a continued behavioral change is that when the consumer enhances their confidence they stand stronger against a difficult situation and do not give up their behavioral change so fast. And
21 the skills to face a problem and deal with it will help them maintaining their new behavior. The proposition is that ‘external problem solving’, ‘self-problem solving’, and so ‘problem solving’ in general play an important role for the continuation of a behavioral change with and without the use of an SST.
Proposition 9a: confidence positively influences the continuation of a behavioral change.
Proposition 9b: an SST positively influences the relationship between confidence and the continuation of a behavioral change.
Proposition 10a: external problem solving positively influences the continuation of a behavioral change.
Proposition 10b: the use of an SST positively influences the relationship between external problem solving and the continuation of a behavioral change.
Proposition 11a: self-problem solving skills positively influence the continuation of a behavioral change.
Proposition 11b: the use of an SST positively influences the relationship between self-problem solving skills and the continuation of a behavioral change.
Proposition 12a: problem solving positively influences the continuation of a behavioral change.
Proposition 12b: the use of an SST positively influences the relationship between problem solving and the continuation of a behavioral change.
22
Challenge
Radhakrishnan and Ronen (1999) explain that more challenging jobs reduce the probability of success but increase the marginal productivity of the agent's effort. This provides the agent with a sense of accomplishment from which the agent derives utility. People need to be stimulated during their continuation of the behavioral change to keep it interesting, otherwise it might get boring. In this way a stimulator can keep patients interested and active. The proposition is that ‘external challenge’, ‘internal challenge’, and so ‘challenge’ in general play an important role for the continuation of a behavioral change with and without the use of an SST.
Proposition 13a: external challenge positively influences the continuation of a behavioral change.
Proposition 13b: an SST positively influences the relationship between external challenge and the continuation of a behavioral change.
Proposition 14a: internal challenge positively influences the continuation of a behavioral change.
Proposition 14b: the use of an SST positively influences the relationship between internal challenge and the continuation of a behavioral change.
Proposition 15a: challenge positively influences the continuation of a behavioral change.
Proposition 15b: the use of an SST positively influences the relationship between challenge and the continuation of a behavioral change.
23
Success
Radhakrishnan and Ronen (1999) found that challenge increased the marginal productivity of the agent’s effort and provided him with a sense of accomplishment. Achieving and
experiencing success seems to be important. When patients start the SMP they formulate a main goal, a big goal where they can work towards. Achieving and gaining success along the way is important to stay motivated. So cutting one big goal into smaller sub-goals will help to get success during the process. Herzberg (2003) argued that achievement is the biggest factor on the job that led to extreme satisfaction. As Wang et al. (2013) showed, satisfaction is one of the factors for continued use of an SST. The proposition is that ‘success’ plays an
important role for the continuation of a behavioral change with and without the use of an SST.
Proposition 16a: Success positively influences the continuation of a behavioral change.
Proposition 16b: an SST positively influences the relationship between success and the continuation of a behavioral change.
Repeated positive experience
Zajonc and Markus (1982) found that enhancement of positive affect towards a given object arises merely as a result of repeated positive stimulus exposure. Nature has provided that the organism will develop preferences for objects with which it has repeated positive experience. So creating positive experiences along the way will not only stimulate and can create multiple success situations but also develop preference for the new (healthier) behavior. So, therefore, the proposition is that ‘repeated positive experience’ plays an important role for the
continuation of a behavioral change with and without the use of an SST.
Proposition 17a: repeated positive experience positively influences the continuation of a behavioral change.
24 Proposition 17b: an SST positively influences the relationship between the repeated positive experience and the continuation of a behavioral change.
Participation in a group or community
The option of participating in a group or community can give patients the feeling that they are not the only ones with a heart disease, creating a sense of togetherness. Furthermore, they can get support from other peers who are in the same process and who are coping with similar problems. This factor of participation in a group can be important for the continuation of a behavioral change. The importance of (small) group bonding and shared interest which influences behavior is also underpinned by Bagozzi & Dholakia (2006) who found positive influences of customer participation in small group brand communities. So the following propositions are formulated:
Proposition 18a: participation in a group or community positively influences the continuation of a behavioral change.
Proposition 18b: the use of an SST positively influences the relationship between participation in a group or community and the continuation of a behavioral change.
From these 18 propositions a conceptual model is created with the 10 factors as independent variables with the proposition that they all have a positive influence on the continuation of a behavioral change and with the moderator (the use of an SST), which is proposed to have a positive influence on the relationship between the factors and the continuation of a behavioral change.
25
(Independent) factors:
- high perceived level of control - fun - motivation - monitoring - confidence - problem solving - stimulation - success
- repeated positive experience - participation in a group or community The continuation of a behavioral change Use of an SST
+
+
Fig. 1. A conceptual model of the roles that the factors and the SST will play on the continuation of behavioral change.
These 10 factors with their 18 propositions are formulated to be able to answer the research question: ‘Which factors positively or negatively influence the continuation of a behavioral change and how does this influence on the continuation of a behavioral change differ when a Self-Service Technology is used?’
26
3. Methods
3.1 Research design
This thesis is an explorative qualitative single case study. Explorative because there is not much known on what factors influence the continuation of a behavioral change (when a Self-Service Technology is used) in the health care industry. The most important factors from a consumer perspective will be explored, just as what the influence of these factors is on the continuation of a behavioral change and what the moderating role of the SST will be.
3.2 Target group
The case study took place in the medical center called Arterium in Amsterdam. The client base of the medical center is used for gaining respondents to interview. The respondents in this study will be cardiac rehabilitators of the CardioVitaal heart rehabilitation program between 32 and 79 years old. At the start of the heart rehabilitation program they are all offered the opportunity to make use of an SST called ‘mijn HealthePortal’ (also known as mijn HeP). This SST offers different features where the patient provides a service without any involvement of the medical personnel. Features like measuring blood pressure can be used which will be passed via the SST (only when the values are above a certain level medical personnel get a notice). The patient can find all kinds of information on ‘mijn HeP’ such as: their whole medical dossier, information about their disease, how far they are in fulfilling their goals, how active they were during the day (via an activity tracker), etc. But also features where they can ask questions to the medical staff and have the possibility to consult an e-Coach are in the SST. The inclusion criteria for the interviews are that the people interviewed are all following (or did follow) the CardioVitaal rehabilitation program at Arterium and have knowledge and experience with ‘mijn HeP’. They all have spent sufficient time with ‘mijn HeP’ to be able to answer the questions regarding the factors that could influence the
27 continuation of a behavioral change. Exclusion criteria are when patients did not follow the CardioVitaal rehabilitation program or are not familiar with the SST. The respondents that fulfill the criteria were approached and asked if they would like to be interviewed regarding the CardioVitaal program/ SST.
3.3 Method
The method that is used during data collection are qualitative in-depth interviews. This to explore what the important factors are from a consumer perspective to influence the continuation of a behavioral change. In total there are 10 factors that are known in the literature to continue behavior and will be examined in this thesis: high perceived level of control (Hui and Bateson, 1991; Lee and Allaway, 2002; Johnson et al., 2008), the use of fun (Dabholkar and Bagozzi, 2002), motivation (Lazear, 1996; Kreps, 1997; Miller and Hom, 1990; Ryan and Deci, 2000; Deci et al., 2001), monitoring (Intille, 2004; Mittag et al., 2006), self-confidence (Pearson et al., 2007; Wang et al., 2013), problem solving (Pearson et al., 2007), challenge (Radhakrishnan and Ronen, 1999), success (Herzberg, 2003), repeated positive experiences (Zajonc and Markus, 1982) and participation in a group or community (no references found). These factors are all possibly important for continuation of a
behavioral change. But there might be more. The user of the CardioVitaal program/SST will be asked open questions regarding the CardioVitaal/SST which may yield new factors from the respondents (other than the 10 factors mentioned above).
3.4 Data collection
28 When no new factors would be mentioned anymore by the respondents, a saturation point of information would be reached. A minimum of 10 interviews would be performed even when the saturation point is reached sooner than 10 interviews. This point of saturation was reached after 9 interviews, in total there were 10 interviews conducted. The topics in the interview are the features of the CardioVitaal program and the SST related to the continuation of a
behavioral change. This is because all respondents are familiar with the features of the
CardioVitaal/SST. The interviews start by asking open questions regarding the features of the CardioVitaal/SST which resulted in a list of new factors mentioned by the respondents. Each interview lasted between 45 and 70 minutes. All interviews were recorded and transcribed. For all factors synonyms are formulated, and after transcribing the interviews were analyzed to look for factors and synonym words.
3.5 Strengths/limitations
The strengths of a single case study are that it will give practical information for this specific case namely the SST in the health care industry. But that is also a limitation. Doing a single case will investigate one research unit, and thereby the research findings are more difficult to generalize to other SSTs in other cases than when performing a multiple case study.
3.6 Analysis
3.6.1 The analysis strategy
The strategy is a mixed strategy partly from Yin (2009) and partly from Glaser and Strauss (1967). The theory of Yin (2009) is used because 17 of the 18 propositions are theoretically based. A code tree of all the propositions is made (see Appendix 1), but it is not explaining
29 any existing theory. A new theory will be created from the factors known from the literature and the new factors mentioned by the respondents. This new theory creation based on the outcomes of the interviews is also known as ‘the grounded theory’, from Glaser and Strauss (1967). This approach is suitable for inductive analysis, the texts are coded based on their content. Theory is developed through analyzing the data (Glaser and Strauss, 1967).
3.6.2 Coding
The analysis technique used in this qualitative research is the conventional content analysis. The coding categories are derived directly from the text data and the summative content analysis, which involves counting and comparing, usually of keywords or content, followed by the interpretation of the underlying context (Hsieh and Shannon, 2005). Then what is analyzed will be partially pattern matching, comparing the gathered data with the
propositions. These propositions are based on the known factors from the literature. The other part of the analysis will be based on the new factors mentioned by the respondents building a (new) theory.
3.6.3 Process
The analysis process started with the preparation, then the categories were created followed by the codes, and finally new codes were added (factors mentioned by the respondents). In the preparation phase cardiac rehabilitators were called by phone to ask if they wanted to
participate in the research by being interviewed. In total 10 participants were extensively interviewed until a point of saturation was reached. All interviews were recorded and transcribed. The next step was analyzing the transcribed interviews and then label all the factors to the proposed categories and codes based on the factors known from the theory (see
30 code tree in Appendix 1). New factors mentioned by the patients were added to the code tree, also known as open coding. Then axial coding followed which is the process of relating codes to each other. Selective coding followed after this, intended to identify one of these principal categories, which becomes known as the central or core category, in order to relate the other categories to this, with the intention of integrating the research and developing a grounded theory (Strauss and Corbin, 1998; Corbin and Strauss, 2008). This phase is based on the integration of categories and focused on finding exceptions or relations to build the theory. After this step the code tree has been fully developed.
31
4. Results
First the results of all the factors that were based on the literature will be discussed, and then the 11 factors that are mentioned by the respondents will be described. In total there are 10 respondents in-depth interviewed, which results in 10 transcribed interviews.
4.1 The results of the 10 factors based on the literature
All of the 10 factors based on the literature were found to have a positive and/or neutral influence on the continuation of a behavioral change. The use of an SST also positively and/or neutrally influences the relationship between the factors and the continuation of a behavioral change. None of the 10 factors based on the literature were found to have a negative influence on the continuation of behavior, neither when an SST was used. All the results can be found in Appendices 2 and 4.
Different situations described during the interview by the respondents created an overlap in answers regarding the influence of the factor on the continuation of a behavioral change. And sometimes respondents contradicted themselves during interviews, which created also
conflicting influences of the factor on the continuation of a behavioral change. Which in practice means that from the 10 interviews a factor: e.g., ‘high perceived level of control’ can have in total 11 counts (8 positive and 3 neutral). In an interview there can be a situation where ‘high perceived level of control’ had a positive influence on the continuation of
32 (in this case) rather neutral. Table 1 below defines when a proposition is declared plausible or not plausible.
Number of interviews that a factor is mentioned in
How often something is mentioned
Plausible / not plausible
1–2 Not a lot mentioned Not plausible
3–4 Barely mentioned Not plausible
5–6 Regularly mentioned Not plausible
7–8 Often mentioned plausible
9–10 A lot mentioned plausible
Table 1. When a proposition is declared plausible or not plausible.
High perceived level of control
The first factor ‘high perceived level of control’ has a positive influence on the continuation of a behavioral change and is mentioned in 8 interviews. Only in 3 interviews a neutral influence was found on the continuation of a behavioral change. The following quotes from the respondents underpin this: ‘After the rehabilitation I continued right away; I signed up at the gym, where I can do my own program; at set times that suit me and started on walking’. Another respondent described it as: ‘You can offer a listening ear and offer all sorts of other things but in the end you have to do it all by yourself, especially after the rehabilitation, and I am ready to continue all by myself’. This factor’s positive influence on the continuation of a behavioral change was mentioned in 8 interviews, which is often and makes the following proposition ‘plausible’ to be true.
Proposition 1a: high perceived level of control positively influences the continuation of a behavioral change.
33 This positive influence is even bigger when an SST is used; 10 out of the 10 respondents confirmed that the SST positively influences the relationship between ‘high perceived level of control’ and the continuation of a behavioral change, which is a lot. The role of the SST in this relationship might be important. The following proposition is therefore ‘plausible’ to be true.
Proposition 1b: an SST positively influences the relationship between high perceived level of control and the continuation of a behavioral change.
Respondents described this as: ‘You can do everything by yourself basically, you are not dependent on the doctors and whether they have time, which is handy’. Another respondent stated that: ‘It saves doctors a lot of time, and it is done easily for me. It saves also time for people who have to do this regularly (measuring their blood pressure), that they don’t have to travel to the doctor constantly but they can do it all by themselves at home’.
Fun
The factor ‘fun’ was tested and was mentioned in 9 interviews to have a positive influence on the continuation of a behavioral change, which is a lot. A neutral influence of this factor on the continuation of a behavioral change was found in 3 interviews. It seems to be important for the continuation of a behavioral change that the behavior must be fun to do. A selection of the quotes from the respondents underpin this: ‘Absolutely, I think that you need to find something, that the patient finds something he likes to do, perhaps a little less active if necessary, but when you don’t do it with joy, then you cannot persevere, then I don’t
persevere’. And another strong quote that underpins this factor: ‘Look, something needs to be fun to do, otherwise I will not keep it up’. An example of a neutral influence was: ‘You are here of course to rehabilitate and after this, to prevent falling back in the same lifestyle as
34 before, it is really important so fun is not essential’. From these results it is shown that this factor is mentioned a lot. Proposition 2a is thereby ‘plausible’ to be true.
Proposition 2a: fun positively influences the continuation of a behavioral change.
When there was no SST used a positive influence was mentioned in 9 interviews, when an SST was used a positive influence was found in almost as many interviews (8). So the use of an SST might positively influence the relationship between ‘fun’ and the continuation of a behavioral change. One of the respondents described this as follows: ‘I like the activity tracker (SST). It keeps track of how much you walk in a day and puts this in a graph. Then you can see how it was going at the beginning of the training in October and how it is going today. Now I walk more outside and I like it because I live healthier.’ A neutral influence on the continuation of a behavioral change was found in only 3 interviews. Because this factor was mentioned often, it is ‘plausible’ that the following proposition is true.
Proposition 2b: an SST positively influences the relationship between fun and the continuation of a behavioral change.
Motivation
This factor ‘motivation’ is a factor on its own and is also split into two sub factors namely ‘intrinsic motivation’ (when people do something because they like it or want to do it, an inner drive sets them to action), and ‘extrinsic motivation’ (when there is, e.g., a reward or stimulation that drives their intentions, so something external triggers them).
There is a positive influence of ‘extrinsic motivation’ on the continuation of a behavioral change according to the results, as this sub-factor is mentioned in 8 interviews. The following quotes from the respondents exemplify this positive influence of ‘extrinsic motivation’ on the
35 continuation of a behavioral change: ‘I see now indeed that I can wear my Diesel jeans again, that is motivating, so if I can achieve that then I want to continue’. That he can wear his Diesel jeans again is seen as a reward for his efforts. And another quote that exemplifies the positive influence of ‘extrinsic motivation’: ‘When you see that your blood pressure is good then that is motivating, and if I also hear this from you guys that it is good, is double
motivating’. This sub-factor is mentioned often and the proposition is thereby ‘plausible’ to be true.
Proposition 4a: extrinsic motivation positively influences the continuation of a behavioral change.
In 9 interviews ‘intrinsic motivation’ has a positive influence on the continuation of
behavioral change as well. A quote that describes this positive influence: ‘‘I sleep really bad at the moment, but nevertheless I get up to go to the gym. For me, this is a big
accomplishment. Then I feel really strong, which gives me strength to persevere. Despite that, working out is not really my thing, I still find it a big accomplishment for myself that I do it. When I didn’t have the motivation to improve my condition as such, then I don’t think I would do it’. This sub-factor is mentioned a lot and the proposition is thereby ‘plausible’ to be true.
Proposition 3a: intrinsic motivation positively influences the continuation of a behavioral change.
The usage of an SST positively influences the relationship between ‘extrinsic motivation’ (mentioned in 8 interviews), ‘intrinsic motivation’ (mentioned in 5 interviews) and the continuation of a behavioral change. Only in 1 interview a neutral influence, when an SST was used, was found on the relationship between of ‘extrinsic motivation’ and the
continuation of a behavioral change. A quote from one of the respondents when an SST was used which positively influences the relationship between ‘extrinsic motivation’ and the
36 continuation of the behavioral change: ‘When it goes well, your numbers go down or up in mijn HeP, it is nice that one of your therapists says ‘it goes well, if you continue like this we can adjust the program’. But because the sub factor ‘intrinsic motivation’, when a SST was used, was only mentioned regularly (in 5 interviews), it has not enough evidence to declare that proposition 3b is ‘plausible’ to be true. When a SST was used this had a positive influence on the relationship between ‘extrinsic motivation’ and the continuation of a behavioral change (this was mentioned in 8 interviews) so thereby is proposition 4b ‘plausible’ to be true.
Proposition 3b: an SST positively influences the relationship between intrinsic motivation and the continuation of a behavioral change.
Proposition 4b: an SST positively influences the relationship between extrinsic motivation and the continuation of a behavioral change.
In all of the 10 interviews the factor ‘motivation’ (which is the results of extrinsic and intrinsic motivation combined) is mentioned (Appendix 4), to have a positive influence on the continuation of a behavioral change. When an SST was used then there was a positive influence found on the relationship between ‘motivation’ and the continuation of a behavioral change, this was found in 9 interviews. So ‘motivation’ seems to be important to influence the continuation of a behavioral change. The following propositions of ‘motivation’ are
‘plausible’ to be true.
Proposition 5a: motivation positively influences the continuation of a behavioral change.
Proposition 5b: an SST positively influences the relationship between motivation and the continuation of a behavioral change.
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Monitoring
The factor ‘monitoring’ is a factor on its own and is also split into two sub factors
‘supervision monitoring’ and ‘self-monitoring’. The choice for splitting this factor into two sub codes is because there is a clear difference between monitoring by supervision (e.g. a therapist, doctor) or by oneself.
The results confirm this, because ‘supervision monitoring’ (mentioned in 8 interviews) seems to have a bigger positive influence to continue the behavioral change then ‘self-monitoring’ (mentioned in 3 interviews). ‘Supervision monitoring’ has an equally strong positive
influence on the continuation of a behavioral change with and without the use of an SST and was mentioned in 8 interviews in both situations. There was one respondent that described a neutral influence of ‘supervision monitoring’ on the continuation of a behavioral change. Some important quotes of respondents to ‘supervision monitoring’: ‘A lot of things happen in your life, and goals like that are easily forgotten; I think it is important for the future to keep on asking questions like ‘you haven’t filled in your measurements lately, what is going on?’; and ‘perhaps 6 months after the rehabilitation or a certain period, from the time people leave here, that you can ask them how they are doing, and once you see that people relapse then you can consider to offer them an adjusted program. Extended follow-up is perhaps a good idea, to keep track on us’. And another respondent said: ‘It works motivating when you fill in your blood pressure values, and I don’t ask to give an instant reaction, because there is a messenger for that sort of questions, but once in the 2 or 3 weeks it is nice to receive a message that someone looked at your values. And you know that you are not filling them in only for yourself, would be nice’. These quotes support the importance of ‘supervision
monitoring’. The results show that this factor is mentioned often and it can be ‘plausible’ that the following propositions are true.
38 Proposition 6a is formulated: supervision monitoring positively influences the
continuation of a behavioral change.
Proposition 6b: an SST positively influences the relationship between supervision monitoring and the continuation of a behavioral change.
‘Self-monitoring’ when an SST is used has a stronger positive influence on the relationship between the factor and the continuation of a behavioral change (mentioned in 6 interviews), compared to mentioning in 3 interviews when there is no SST used. The respondents described ‘self-monitoring’ situations as follows: ‘It becomes fun as well to keep track of it, when it is so simple. It is like a sort of diet diary, with in it direct feedback in a graph ‘oh then my weight went up because I ate that and that’. That is immediately a motivation and a challenge to keep up a healthier lifestyle”. Another respondent said: “Your neighbor has a graph and says: ‘well I looked yesterday and it is going much better already’ and if you cannot say the same thing then that works motivating for you to do better. Of course you cannot look constantly at others, but if you look at your own statistics and you see that it is going worse, then you think: ‘guys come on, we can do better than this’. So for me it works really well.’
Because ‘self-monitoring’ was only mentioned a few times (in 3 interviews) to have a positive influence on the continuation of a behavioral change, proposition 7a cannot be declared ‘plausible’ to be true, because there is not enough evidence to underpin this. Proposition 7b can also not be declared ‘plausible’ despite, when an SST was used, it had a positive influence on the relationship between this ‘self-monitoring’ and the continuation of a behavioral
change, but this was only mentioned regularly (in 6 interviews).
Proposition 7a: self-monitoring positively influences the continuation of a behavioral change.
39 Proposition 7b: an SST positively influences the relationship between self-monitoring and the continuation of a behavioral change.
In 8 interviews the factor ‘monitoring’ (supervision and self-monitoring combined) was mentioned, and in 9 interviews the factor ‘monitoring (supervision and self-monitoring combined) with the use of an SST’ was mentioned (see Appendix 4). In both situations it had a positive influence on the continuation of a behavioral change (with and without the use of an SST). So ‘monitoring’ seems to be important to influence the continuation of a behavioral change. The following propositions of ‘monitoring’ are ‘plausible’ to be true.
Proposition 8a: monitoring positively influences the continuation of a behavioral change.
Proposition 8b: an SST positively influences the relationship between monitoring and the continuation of a behavioral change.
Self-confidence
The factor ‘self-confidence’ was mentioned in 6 interviews to have a positive influence on the continuation of a behavioral change. A neutral influence of this factor on the continuation of a behavioral change was found in 3 interviews. It might be important for patients to have self-confidence to continue the behavioral change, but it was only mentioned regularly. A selection of the quotes from the respondents will clarify this: ‘I don’t want to be a suffering person, like there are a few people that walk in front of me and pull the cart. No I’m doing this myself, that is the only way to maintain this healthier behavior’. And another strong quote that supports this factor: ‘Now I’m so far that I have gathered enough confidence that I don’t need any guidance by a professional anymore, I continue on my own’. An example of a neutral response was: ‘You fall back in an old habit really easy, despite that you have
40 confidence. I have confidence, absolutely but I relapse into old habits quiet often’. The results show that this factor was mentioned only regularly (in 6 interviews) which is not enough evidence that this factor is important or plausible to be true to continue a behavioral change.
Proposition 9a: self-confidence positively influences the continuation of a behavioral change.
The use of an SST positively influences the relationship between ‘self-confidence’ and the continuation of a behavioral change and was found often in 7 interviews. A respondent described this as follows: ‘the more questions that patients get answered after the
rehabilitation (via mijn HeP), the larger your self-confidence becomes. Because you have people that monitor you and keep an eye on you via this website’. A neutral influence on the continuation of a behavioral change was found in only 1 interview.
From this result self-confidence seems to be an important factor for the continuation of a behavioral change. Patients need to have self-confidence because they do not want to be a suffering person, others on the other hand say that self-confidence may have not such a strong influence on the continuation of behavior. This is in line with the clarification of the
previously stated proposition, but because it was mentioned often, the following proposition is ‘plausible’ to be true.
Proposition 9b: an SST positively influences the relationship between confidence and the continuation of a behavioral change.
Problem solving
The factor ‘problem solving skills’ is a factor on its own and is also split into two sub factors namely ‘external problem solving’ and ‘self-problem solving skills’. External because it is also possible that patients find someone else to solve their problems or can come with advice
41 how they should solve their problem, but the patient can do it also by him/herself which is why the other sub factor is called ‘self-problem solving skills’.
The factor ‘external problem solving’ was mentioned not a lot, only in 2 interviews to have a positive influence on the continuation of a behavioral change. This will not be enough evidence to declare that proposition 10a is ‘plausible’ to be true.
Proposition 10a: external problem solving positively influences the continuation of a behavioral change.
The factor ‘self-problem solving skills’ in comparison was mentioned often (in 8 interviews) to have a positive influence on the continuation of a behavioral change. A quote from one of the respondents: ‘When I ate bad, the next day I did not eat or only with low carbohydrates; this way I solved the problem that I still keep on losing weight’. Therefore this proposition is ‘plausible’ to be true.
Proposition 11a: self-problem solving skills positively influence the continuation of a behavioral change.
The results show that when an SST is used, this has a positive influence on the relationship between the ‘external problem solving’ and the continuation of a behavioral change. This was mentioned often (in 7 interviews). A quote that illustrates this positive influence: ‘It would be nice if you could ask your questions somewhere, especially when you cannot solve them on your own, that you can find someone who can help you’. And another respondent said: ‘It is nice if you get feedback on questions and problems, a sort of help, a sort of digital help would be nice, it doesn’t seem so weird to me’. So the SST positively strengthens the relationship between the ‘external problem solving’ and the continuation of the behavioral change. A neutral influence of this factor on the continuation of a behavioral change was found in just 1 interview. Therefore the following proposition is ‘plausible’ to be true.
