Developing cue-behavior association for habit formation: A qualitative study to explore the role of avatar in hypertension

Background: Electronic health (eHealth) has been widely adopted in chronic disease management. Prior studies focused on time-based reminders as a cue to facilitate behavior change intentions, ignoring the development of automatic cue-behavior associations via other cue types. Objective: Hence, this study utilized avatar appearance as a visual-based cue to help establish the automatic association between appearance transformation and health behavior to form habits without intention. Methods: To better understand users’ attitudes and experiences toward applying changes in avatar appearance to develop cue-behavior associations for hypertensive patients. Fifteen participants were recruited in a 14-day experiment. After excluding one participant who dropped out of the experiment, others were randomly assigned to two groups. One group consisted of a visual-based cue (a virtual plant) and basic behavior change techniques (BCTs). The other group only included basic BCTs. Attitudes and experience outcomes were collected by interview, and qualitative data were analyzed using thematic analysis. Results: 57% of participants had been diagnosed with hypertension for more than five years, and more than 50% of participants have experience using mobile apps or wearables. 66% of participants did physical activity more than three times every week. The result shows that tailored time-based reminders, blood pressure monitoring, and daily dietary intake were the most attractive features. Additionally, hypertensive participants have positive attitudes toward avatar appearance as a visual-based cue to develop cue-behavior association, which enhances self-management motivation. Conclusion: This study proposes a visual-based cue design for habit formation and conducts a qualitative method to explore hypertensive patients’ perceptions. The findings offer insights from user's perspectives into hypertensive patients’ attitudes toward visual-based cues and perception of the connection between avatar appearance and health behavior for self-management. Subsequent discussions present eHealth design guidelines of habit formation from intention, automatic cue-behavior association, and self-management perspectives.