Five principles for developing digital clinic-based, behavior-change health interventions

Digital health interventions have the potential to improve population health, can be taken to scale rapidly, are cost-effective, and can reach a broad population. Widespread access to and use of digital technologies have contributed to an increase in digital health interventions to support behavior change in many health arenas, such as HIV prevention and treatment, cardiovascular disease prevention, physical activity promotion and obesity prevention, pregnancy prevention, and smoking cessation.

The convergence of technology and clinic-based behavior change interventions creates an exciting yet challenging opportunity. On the one hand, researchers and practitioners can now reach people more precisely than before. On the other, these technologies require new alliances, input from different kinds of stakeholders, and content creation that goes beyond traditional means.

CDC’s Positive Health Check (PHC) is a video-based digital counseling intervention for HIV-positive patients in clinical care. The lessons we learned by developing PHC can add to the knowledge base of existing frameworks and recommended practices for developing digital health interventions. Five principles guided the development of Positive Health Check: Team Science, Theory, Data Security, User-Centeredness, and Sustainability. These principles, described in more detail below, helped ensure the feasibility and acceptability of the intervention in clinic settings.

Principle 1: Team Science

A “team science” approach addresses barriers to effective intervention development and implementation in clinical settings.

Digital interventions in clinical settings need to draw on the expertise and capacity of many individuals. Information technology professionals can develop and manage technologies that work, but researchers understand behavior-change interventions, and healthcare professionals can consider the implementation context and clinic workflows. Team science approaches can help to inform the development and management of interdisciplinary teams needed to create effective digital health interventions for clinical contexts. Research from this field demonstrates that teams produce more frequently cited research than individual investigators, supporting the engagement of teams over individual investigators.

Principle 2: Theory

Digital health interventions should be theory-based.

As described by Pingree and colleagues, theory is an especially important foundation for digital health interventions. Unfortunately, many digital health interventions currently available are not grounded in theory. Theory-based strategies can enhance the usage and impact of digital health interventions on behavior change. For example, strategies such as tailoring content to increase motivation come from the Elaboration Likelihood Model and Self-determination Theory. These theoretical perspectives predict that tailoring makes information more relevant and may increase the likelihood of patients’ engagement and subsequent behavior change.

Principle 3: Data Security

Privacy and data security are paramount.

The use of tablets, mobile phones, and other technologies for clinic-based digital health intervention delivery introduce additional layers of complexity for patient privacy and data security. Legal and ethical issues include privacy, confidentiality, data validity, potential misuse of interventions by professionals, equality of Internet access, and credentialing issues. Federal agencies such as the Federal Trade Commission (FTC) have released guidelines for developers, and a number of states have passed laws to specifically protect the privacy and data of mobile app users. We suggest that developers carefully evaluate methodological, technical, and procedural security issues, conforming to rules and regulations in the clinical settings where they seek to implement. Users should know who can access their information and where it will be stored.

Principle 4: User-Centered

Designing for engagement requires user input and testing.

New forms of technology are continually available and constantly competing for our attention. To ensure that an intervention has the potential to rise above the noise, it is important to follow user-centered design processes and build in features known to increase engagement. This will support end-user engagement, improve the user’s experience, encourage attentiveness toward the intervention at hand, and facilitate wider adoption.

In fact, we (and others) strongly urge researchers to collaborate with end-users from the very beginning of the intervention design process. This will help to determine their needs, how to best meet them, and how to most effectively engage people in the intervention. Ideally, researchers should allow for an iterative design cycle with multiple feedback loops, as opposed to obtaining feedback at a single time-point.

Principle 5: Sustainability

Planning and designing for adoption, scale, and sustainability is critical.

Digital interventions have many advantages over traditional intervention delivery channels. They are affordable to adopt compared to small-group and community level interventions, easy to update and are easier to scale up. These advantages can be enhanced by designing digital health interventions with sustainability in mind [PDF]. To achieve this, use technology that can be accessed by as many different platforms as possible, and build in ways to disseminate updates as new knowledge and health information emerges and as technology changes.


We found these five principles helpful to improve the efficiency of our digital health intervention. These principles may be useful to others developing and disseminating effective interventions.

This infographic, presented as a poster at the 2017 APHA conference, shows how these five principles improved the development of the Positive Health Check intervention. Click picture for full size version.

Olivia Burrus

Olivia Burrus

Behavior Change Researcher at RTI International
Olivia Burrus is a behavior change researcher passionate about improving health and wellbeing through innovative, theory-driven solutions and human-centered design. In 2011, she received her Master's in Public Health from the University of North Carolina, Chapel Hill. Presently, Ms. Burrus is working in RTI International's Center for Communication Science where she conducts research and evaluations of communications materials, social marketing campaigns and behavior change innovations across a variety of subject areas including HIV, informed decision making, patient-provider communication, risk communication, health literacy, financial literacy, and global health.
Olivia Burrus
Olivia Burrus

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Catherine Gupta

Catherine Gupta

Catherine Gupta graduated in 2011 from the University at Buffalo with a Bachelor of Science in Pharmaceutical Sciences. In 2015, she received her PhD from the University of North Carolina at Chapel Hill Eshelman School of Pharmacy. Presently, Dr. Gupta is working at RTI International as a health communication research scientist. Her research focuses on patient-provider communication, direct-to-consumer advertising of prescription medications, and the development and evaluation of decisions aids for HIV prevention and management and informed consent.
Catherine Gupta

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Alexa Ortiz

Alexa Ortiz

Health IT Scientist at RTI International
Alexa Ortiz graduated from the University of North Carolina at Charlotte in 2009 with a Bachelor of Science in Nursing. Before receiving her graduate degree she was a practicing nurse for five years and has clinical experience in the field of both Cardiology and Neurology. In 2014 she received a Master of Science in Nursing specializing in nursing informatics from Duke University. Presently, she works as a Health IT Scientist at RTI International in the Center for Digital Health and Clinical Informatics. Despite no longer working in a clinical setting, she continues to maintain an active nurse license in the state of North Carolina. Her primary areas of research at RTI International focus on the clinical implementation of health information technology and the evaluation of consumer wearable devices.
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Camilla Harshbarger

Camilla Harshbarger

Camilla Harshbarger, Ph.D., is an anthropologist working at the Centers for Disease Control and Prevention’s Division of HIV/AIDS Prevention to lead the development and effectiveness trial of Postive Health Check, an online video counselling intervention designed to improve viral suppression of people living with HIV and engaged in clinical care. Dr. Harshbarger led the CDC’s first Google Hangout featuring experts from community based organizations to share their lessons learned recruiting into HIV prevention programs young men of color who have sex with men. She co-led the Diffusion of Effective Behavioral Interventions (DEBI) project which trained about 14,000 individuals to implement interventions with people at risk for HIV. Earlier in her career, Dr. Harshbarger consulted in international development in Africa and Latin America. She holds a Ph.D. in cultural anthropology from the University of Florida in Gainesville.
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