Persuasive Design Techniques and App Design Recommendations to Improve Health Workforce Capability in Rural Health Professionals: What Do Users Want and How Does an App Help?

Background: Health professionals’ perceptions of persuasive design techniques for use in technological solutions to improve health workforce capability have not been previously explored. Objective: This study aims to explore rural health professionals’ perceptions of health workforce capability and persuasive design techniques; and translate these into recommendations for designing a health workforce capability app to increase their impact and usefulness. Methods: Qualitative interviews with 13 rural health professionals were conducted. Subsequently, 32 persuasive techniques were used as a framework to deductively analyze the data. Persuasive design technique domains were Primary Task Support, Dialog Support, System Credibility Support, Social Support, and Cialdini’s Principles of Persuasion. Results: Persuasive design techniques can be applied across the factors that influence health workforce capability including health and personal qualities; competencies and skills; values, attitudes, and motivation; and factors that operate outside of work and at the team, organizational, and labor market levels. The majority of the 32 persuasive design techniques were reflected in the data from the interviews and led to recommendations as to how these could be translated into practice, with the exception of scarcity. Many suggestions and persuasive design techniques link back to the need for tailored and localized solutions such as the need for country-specific–based evidence, the wish for localized communities of practice, learning from other rural health professionals, and referral pathways to other clinicians. Participants identified how persuasive design techniques can optimize the user experience to help meet rural health professionals needs for more efficient systems to improve patient access to care, quality care


Introduction
Background Globally, people in rural areas are disadvantaged when it comes to seeking health care [1,2]. This manifests as poorer health outcomes and has, in part, been directly attributed to persistent recruitment and retention challenges in rural areas [3]. Additionally, high levels of burnout are reported among rural health professionals across the globe [4,5]. For example, 47.6% of rural Chinese primary health care workers reported moderate burnout and 3% severe burnout [5].

Health Workforce Capability
There is a growing body of evidence that aims to address the barriers to, and enablers of, recruiting and retaining a rural health workforce [3,6]. For example, multiple initiatives are aimed at incentivizing work in rural areas for health professionals [7], and others demonstrate the potential effectiveness of regulatory change such as increased scope of practice for nurse practitioners [8]. Specifically, workforce capability plays a significant role in the attraction, recruitment, and maintenance of health practitioners in a rural setting [9]. Health workforce capability describes "a health professional's overall ability to fulfil their health care role" [9]. Health workforce capability can be defined as "the intersection between individual capacity and ability to adapt to work considering the whole of health care context, including the labor market, population needs, family, schools, partner, education, and social options." Thus, health workforce capability is a complex construct that consists of much more than just clinical competence. It is a holistic concept that considers the multidirectional interactions both internal and external to the individual practitioner [9][10][11]. Internally, it considers interactions between an individual practitioner's personal and professional spheres, both of which are complicated domains that vary greatly between individuals. Externally, workforce capability takes into account the interactions between the professional and their environment, including their employer, co-workers, and social circles. For rural health professionals, it also takes into account patients, clients, and the communities they serve. Despite the clear importance of understanding capability in the context of the rural health workforce, it is an underexplored area.

Digital Technology and Health Workforce Capability
Before the role of technology in the clinical context was forced into the limelight due to COVID-19 [12], rural health professionals globally had long been using digital solutions [12] to bridge large geographical distances. Complementary to this, recent studies have demonstrated technology's role in supporting the workforce capability of the rural health workforce [13]. Indeed, it has been suggested that employing technology solutions in the rural context can improve the capability and retention of rural health professionals [13]. What then are the appropriate solutions to improve health workforce capability? To answer this question, the authors of this paper undertook 2 previous studies [10,11].
The first study investigated the wants and needs of the rural health workforce to improve their capability and the potential role of technology in assisting them [10]. Theories around the acceptability of information technology solutions, including the Mobile Application Rating Scale (MARS) [14], the Technology Acceptance Model (TAM) [15], and the Health Information Technology Acceptance Model (HITAM) [16] were used to address this question. The study identified 7 factors that had the greatest influence on health workforce capability: health and personal qualities; competencies and skills; values, attitudes, and motivation; and factors that operate outside of work and at the team, organizational, and labor market levels.
The second study consisted of reviewing apps in Google Play Store and technical design elements that allow the technology solution to fulfill the wants and needs of health professionals [11]. Persuasive design techniques can be used to encourage people to use a product or to take certain actions or to make certain positive decisions. Persuasion is a complex concept and can use computer-human or computer-mediated approaches. Computer-human approaches are computer driven, yet need to be programmed, so the developer has a critical role to play and has a large impact on design. Computer-mediated persuasion [17] occurs through using digital social communication tools. In the health context, this could include, for example, chats, interactive webinars, and virtual clinics where health professionals would persuade each other. Specifically, this second study investigated persuasive design techniques used to improve use of existing capability-building-related apps, and offered some basic suggestions for incorporating these techniques into a health workforce capability app to increase its persuasiveness. It used theories on persuasive design elements that influence behavioral change, including the Persuasive System Design Model (PSD Model) [17] and Cialdini's Principles of Persuasion [18,19]. A total of 32 persuasive design techniques were studied clustered by 5 design features categories: Primary Task Support, Dialog Support, System Credibility Support, Social Support, and Cialdini's Principles. The design techniques are further explained in Tables 1-5. While several studies have tried to understand the 2 questions independently [20,21], to our knowledge, none have examined improving health workforce capability on their own, let alone mapping the 2 together. To fill this gap, this study will map persuasive design techniques with the health workforce capability needs and perspectives of rural health professionals within the context of improving health workforce capability.  • Health professionals lead discussion groups.

•
Health professionals demonstrate innovations that others feel can be replicated.
A system that is visually attractive for its users is likely to be more persuasive.

• •
An app has professionally developed and visually attractive content.
And I did the preventing dementia one, and that was fantastic because it was very professional, and it was multiple modules over four weeks.  A system that highlights people or organization behind its content or services will have more credibility.
Real-world feel

• •
App provides information about the organization or rural health professionals or both. • Link to an official government-recognized network.
Third-party endorsements, especially from well-known and respected sources, boost perceptions on system credibility.   c Causes people to almost panic out of the fear that something will disappear or become unavailable, so they make an intent effort to acquire or preserve it.

Scarcity
• Circulation of grant opportunities with an emphasis on deadlines.

Objectives
This study aims to: 1. explore rural health professionals' perceptions of health workforce capability and persuasive design techniques; 2. translate these into recommendations for designing a health workforce capability app to increase their impact and usefulness.

Data Collection
A qualitative analysis of interview data used in the 2 previous studies was conducted to evaluate how persuasive design techniques can be used to build a health workforce capability app. As outlined in Ramsden et al [10], 13 rural health professionals were interviewed about their understanding of health workforce capability, their perceived needs to improve health workforce capability, and how technological solutions can assist in improving rural health workforce capability and intentions to remain in rural practice.
Interview questions were informed by the work of Anderson and co-workers [22] and Jeffrey and colleagues [23] in terms of focusing on technology acceptance and behavior change.
Persuasive strategy questions were informed by the work of Oyebode and co-workers [20] as described above.
Recruitment occurred via the telephone, in person, or through the Rural Health Pro newsletter. Rural Health Pro is a digital platform that links health professionals and organizations interested in rural health [24]. A plain language statement was emailed to participants expressing interest. An interview time was established after consent. Telephone interviews were conducted by RR and SP, digitally recorded, and transcribed. Transcripts were not returned to participants for comment, verification, or correction. Upon transcription, identifying information was removed. The transcribed interviews were managed in MS Word. Both RR and SP have extensive experience in conducting qualitative interviews. SP has lived rurally since 2005 and worked in rural health research since 2006. RR has worked in rural health since 2012. These experiences have shaped the interviewers desire to improve rural health workforce.
Participants included general practitioners (GPs), a pain specialist, nurses, and allied health practitioners. The group comprised 4 males and 9 females. Age ranged between 39 and 65 years, with an average age of 51 years. Interviews took on average 46 minutes (range 29-98 minutes). The interviewers had no previous existing relationship with the participants. RR and SP undertook reflexivity exercises during the data collection to ensure rigor, in addition to the checks during analysis listed below. RR and SP recognized that they have an interest in improving rural health workforce capability using technology. Both ethical and practical issues that arose during the interviews were discussed between the 2 interviewers to ensure alignment and rigor when conducting the interviews.

Analyses
Our systematic review of persuasive apps that are related to health workforce capability generated examples of how the various techniques can be used in practice to develop a health workforce capability app. Subsequently, the 32 persuasive techniques [11,[17][18][19] were used as a framework to deductively analyze the data. Descriptions of the 32 persuasive design techniques are listed in Tables 1-5.
Verbatim transcripts were coded manually. The first 2 recordings were coded separately by 2 authors (KP and RR). The remaining 11 interviews were coded primarily by authors KP and SP. RR and AT were involved in coding transcripts and reaching consensus. SP and KP subsequently used the coded data to analyze and identify quotes to support the development of suggestions for how persuasive design techniques can be used to build a health workforce capability digital tool. The findings were discussed and checked by RR and AT to ensure validity of the data. JB provided specific feedback on user design and discussions were held to further shape the data interpretation.

Ethical Approval
The study was approved by the North Coast NNSWLHD Human Research Ethics Committee (2020/ETH03020).

Results
Tables 1-5 show how health professionals' needs and suggestions are reflected in the 32 persuasive design techniques that can be used when building a health workforce capability online support tool.
The results are displayed by the main domains in persuasive design techniques: Primary Task Support, Dialog Support, System Credibility Support, Social Support, and Cialdini's Principles of Persuasion. The researchers analyzed the qualitative data to identify how health professionals' perspectives could be translated into recommendations for designing a health workforce capability app to increase their persuasiveness. The majority of the 32 persuasive design techniques were reflected in the quotes from the interviews and led the researchers to a recommendation as to how these could be translated into practice, with the exception of competition and scarcity.
Primary Task Support techniques, for example, may be utilized to guide health professionals through a clinical protocol or professional development activity by reducing complex behaviors into simple tasks, tailoring evidence-based information to needs, and personalizing content (eg, Australian guidelines). Further, techniques such as simulation would enable health professionals to observe other clinicians performing procedures and rehearse behaviors themselves, accommodating health professionals' ideas of how they would like to use an app to build capability.
Health professional perspectives also highlighted the importance of credibility for app design. For example, under the domain System Credibility Support ( Giving feedback to support health professionals to move toward their goals, such as rewards and praise in the form of continuing professional development points or encouragement for goal-directed behaviors, is a suggested design feature. Further, reminders about target behavior, such as taking a break, and suggestions related to capability-supporting behaviors that are suitable or appropriate to health professionals were examples provided that align with Dialog Support techniques.
Further analyses revealed that health professional needs and digital solutions mapped against persuasive techniques broadly align with the factors affecting health workforce capability. The analyses are summarized in Table 6. Based on health practitioners' insights and suggestions, practical recommendations have also been presented in Table 6. It is noted that the findings are not necessarily mutually exclusive given the complexity. For example, depending on the level and governance, the recommendation about communities of practices on team level can also be viewed as Primary Task Support and Social Support if, for example, a national or state body would manage the communities of practice. The recommendation relating to organizational level refers to the fact that referrals and closed-loop communication are professional activities that form part of the practitioner's primary scope of work. Thus, this function would be simplifying a process that already takes place and falls within the definition of reduction. The design techniques appear acceptable to rural health professionals and can be incorporated into future apps that focus on improving or maintaining health workforce capability across several areas. A reminder on an app to take a break to recover. Self-monitoring Dialog Support • • Improved fitness through an exercise monitoring and scheduling app. Reminder

Competencies and skills
System Credibility Support • • An app that provides extensive clinical knowledge based on latest evidence and specialist contributions.

Expertise
• Clinical competence building through online education.

Values, attitudes, and motivation
System Credibility Support • • Increased credibility by not displaying pharmaceutical advertisements on apps.

Surface credibility
Social Support • • Published stories of people being publicly recognized for work they have done to demonstrate members are being valued.

Recognition •
Social learning • Social facilitation

Factors outside of work
Social Support • • Using chatrooms to allow for real-time discussions and to see other rural health professionals taking a holiday.

Team level
Cialdini's principles Health professionals participating in a community of practice and helping each other with clinical problems or capability-related issues.

Organizational level
Primary Task Support • • GPs a being able to book patient appointments for allied health professionals online and that which link back to the GP so both parties receive reports. This could potentially work both ways. Allied health professionals being able to book appointments with the GP for their patients.

Labor market
Primary Task Support • • Job vacancies for rural health professionals are tailored to health care professionals' interest and discipline.

Principal Findings
A qualitative analysis of semistructured interviews with rural health professionals was undertaken to investigate the alignment of user perceptions of health workforce capability with persuasive design techniques. These findings were then translated into recommendations for designing a health workforce capability app to increase their impact and usefulness (Tables 1-6). The authors found that the persuasive design techniques can be applied across the factors that influence health workforce capability including health and personal qualities, competencies and skills, values, attitudes, and motivation, as well as factors that operate outside of work, and at the team, organizational, and labor market levels. There is alignment between the needs of health professionals and persuasive design techniques. The health professionals' interviews clearly identified the persuasive design techniques that were appealing. Many suggestions link back to the need for credible, tailored, and localized solutions such as having Australian-based evidence, localized communities of practice, access to learning from other rural health professionals, and referral pathways to other clinicians.
It was also clear that rural health professionals in our study aspired to have more efficient systems to improve patient access to care, quality care, and to enable working in interprofessional team-based care. Persuasive design techniques that can assist here are, for example, tailoring, reduction, social roles of digital technology, and authority. These techniques can influence team and organizational factors to improve health workforce capability. Indeed, the need for team-based care is an old adage, and barriers and facilitators to this have been explored over time [25]. Notably, our previous work [10] demonstrated that COVID-19 has accelerated the capability and willingness for team-based care arrangements in primary and remote care through using digital solutions. This study has clear recommendations as to how persuasive design techniques can be used in digital solutions to further improve patient access, quality care, and promote team-based care. For example, one GP recommended that GPs should be able to book an appointment with a local allied health professional with an online booking system (Primary Task Support) so the patient does not have to do that. This ensures the patient is booked in (tunneling) and reduces the risk of the patient not following up with their allied health appointment, thereby enhancing the quality of care as well as the GPs own health workforce capability. Ways in which this system may improve a GPs and allied health professional's workforce capability are reduced red tape and less inconvenience in making referrals; improved close loop communication that reduces the workload for the GP and the allied health professional; better outcomes for patient that leads to further reduction in the future workload; positive feedback to GPs and allied health professionals (recognition); and improved job satisfaction for both allied health professionals and GPs as closer relationships may be developed overtime.
Overall, health professionals were open to self-monitoring of their work performance and some already regularly use wearables to monitor their health. Although using wearables to measure work performance and stress levels at work has potential [26], it is still in its infancy. A 2019 randomized controlled trial showed that using wearables to improve emergency physicians' well-being through monitoring their pulse rate while at work was feasible but not recommended [27]. The authors found that the biosensor could not provide reliable estimates of metrics of interest in their study context. However, Ferdous and colleagues [28] found that patterns of smartphone app usage were correlated with stress levels in work environments and thus recommended that these could be used to measure stress at work. Alhasani et al [29] presented the possibility of an app that creates behavioral data, based on self-report and sensors, that can be analyzed in real-time to predict users' needs and provide tailored interventions for the user. In the case of rural health workforce capability, if a health professional's heart rate variability indicates high stress levels derived from a sensor, the app can recommend a predetermined meditation session. The behavioral data can also be merged with self-reports generated by in-app journals or self-report. Synthesizing and interpreting this information using machine learning could improve the accuracy of predictions and hence provide more targeted and personalized recommendations for the user.
Social inclusiveness is a known contributing factor for improved health workforce capability [10]. Therefore, computer-mediated persuasion [17] using digital social communication tools that have a real-world feel and demonstrate that there are real people and experts (surface credibility) behind a digital tool or content is important. Health professionals will be more likely to engage with a digital system if they know that real people and respected experts are involved. In a study of nurses, Mayer and colleagues [30] found that approximately half of the nurses used apps for their work and stressed the importance of apps being validated by credible bodies before they can be used in practice. Expert design, content, and involvement will lead to greater system credibility and also improved social connections and support channels for rural health professionals. This stresses the importance of policies to ensure high-quality membership of digital communities and, thus, system credibility (persuasive design technique) to guarantee impact and engagement with the tool. Ultimately, the quality of the online membership can have an impact on usage and engagement of health workforce capability apps. Therefore, factors to consider when developing an app are closed or open membership; verification of credentials; potential publication of credentials; role and credentials of moderators; and rules of participation.

Validation of Persuasive Systems Design Model and Persuasive Design Theories
Our work has contributed to the further validation of the Persuasive Systems Design model [17] through empirically aligning elements of the model to increase persuasive system content and functionality with real-world applied data, in this case the health workforce capability of rural health professionals. We analyzed the use context through identifying problem domain-dependent features which are the factors that influence health workforce capability [10]. We also analyzed the user context that are the user-dependent features such as goals or motivations of health professionals [10]. Subsequently, we analyzed the technology context through identifying the technology-dependent features for health workforce capability-related apps [11]. In this paper, we then described example software apps and implementations. Some of these examples are relatively novel in addressing health workforce capability needs such as geolocation of health professionals in a rural area to reduce social isolation [10] and some are already used in varying capability building-related apps such as easy access to clinical guidelines to increase medical performance [31] in apps such as UptoDate [11] or online communities such as Rural Health Pro [24]. Rural Health Pro is a digital platform that connects people and organizations who care about keeping rural communities healthy. Notably, we found that sometimes comments made by health professionals could apply to several persuasive design techniques. This is confirmed by feedback from user experience designers that, for example, tailoring and personalization are often the same in practice.

Study Strengths and Limitations
Overall, the alignment between the needs of health professionals and persuasive design techniques to improve health workforce capability through optimizing the user experience means that we can support rural health professionals which may lead to greater retention [9,11,13]. The above findings are important as they confirm that these techniques can be used to develop a future prototype that may assist health professionals in improving or maintaining their health workforce capability which in turn may increase recruitment and retention in rural areas. However, we stress that it is unlikely that a single app could cover all persuasive design techniques explored in this paper, nor do we imply a health workforce capability app should do so. For example, if we built a health workforce capability app for GPs, it likely would not have the ability to book appointments for allied health professionals as that may not make sense from a product or commercial perspective to bundle and market those features together. Additionally, a system itself needs to provide enough value and solve a problem for health professionals, regardless of the number of persuasive techniques built into the app. A very useful system without any or a limited number of persuasive techniques could still improve health professional capability. Persuasive design techniques are only one element to consider in the development process of a health workforce capability app. For example, usability heuristics are useful to develop an easy-to-use interface, marketing campaigns may be necessary to promote uptake of a health workforce capability app, and service blueprinting can be used to guide the whole process.

Ethical Considerations
It is important to consider the ethic factors in using persuasive strategies. Jacobs [32] explored the use and ethical concerns of persuasive technology for vulnerable people. While health professionals are not considered vulnerable overall, they can be vulnerable when working in isolation for long periods and this may be exacerbated by the COVID-19 pandemic and other natural disasters such as bushfires, droughts, and floods. Their strong sense of responsibility and commitment to their patients and community make health professionals potentially more vulnerable over time as their energy levels and resources are depleted [33]. However, the point of using persuasive design techniques in digital solutions is to make health professionals feel more capable when they are feeling overstretched or underconfident. The implication is that thorough consideration of, and trialing of, appropriate strategies is important.
Vulnerability can be caused by intrinsic factors (within a person) or can be caused by external factors that are situational specific [32]. An example of situational vulnerability is that an app may be designed for support but reduces the health professional's privacy, and increases feelings of being watched. It may also increase their feelings of anxiety about the potential for negative consequences if their capability goes down, and they could potentially start to feel powerless. The ethical concept of autonomy may be violated in this example.
The design should ensure that the user, in this case, the health professional, can easily retract their consent to take part to avoid coercion [32]. This should include the ability to withdraw any data already submitted or collected about them. This will have the secondary function of improving engagement as the participants are assured of the ability to cease their involvement at any time. For example, a rural health professional when highly capable may be willing to partake in an app that measures their capability; however, if they feel less capable for any reason, it may well be that they become increasingly vulnerable. Completing a rating on a regular basis can make people aware of their shortcomings and have unintended consequences [32], such as exacerbated feelings of incompetence or reinforcing unconscious incompetence.
Jacobs [32] recommends that to safeguard against unintended consequences, technology designers should understand the experiences, interests, and needs of prospective users through inclusion of vulnerable populations at every stage of the design process. Our study described here has done that and is the first step in the co-design process. Designers need to ensure they understand the values, needs, and interests that are important to the users. A second safeguard is to take into account real-life contexts, which can reduce unintended negative consequences [32]. The latter issue demonstrates the importance of considering a digital tool as part of an integrated approach that includes a real-life support component. Finally, there must be a clear and continuous feedback mechanism where users can identify and raise issues of concern for the developers to remedy.
Organizations developing or managing apps or online communities would need to ensure high-quality online membership. Ethical principles, membership criteria, and policies will need to be developed to ensure mechanisms are in place to ensure members or users genuinely represent the purpose and values of the community.
To design a digital health workforce capability solution, it is important to select and apply an ethical framework that fits the health workforce capability needs and assists in carefully weighing up risks and benefits. Many ethical frameworks exist in the medical research field. They can be disease specific or goal specific such as an ethical framework for COVID-19 contact tracing [34] or more general such as the work conducted by Tokgöz and co-workers [35] who developed an ethical framework for health and medical apps based on a systematic review and expert interviews. However, it is ultimately recommended to use an ethical framework that aligns with international standards. Several international standards are available and selection of a standard will depend on the context of the app such as 'ISO/TS 82304-2:2021 Health software -Part 2: Health and wellness apps -Quality and reliability' [36] or 'the ISO/TS 17033:2019 Ethical claims and supporting information -Principles and requirements' [37]. The latter can be used when specific standards are not available or can complement existing standards. It covers principles and requirements for developing and declaring ethical claims.
Given that rural health professionals are often subject to burn out due to isolation, high stress, long working hours, lack of local staff, and limited resources, being able to provide a technology solution with persuasive strategies to boost capability is a positive aspect.

Conclusions
Rural health professionals' perceptions of health workforce capability informed which persuasive design techniques can be used to optimize the user experience of an app. These were translated into recommendations for designing a health workforce capability app to increase likelihood of adoption. This study has also contributed to the further validation of the Persuasive Systems Design model through empirically aligning elements of the model to increase persuasive system content and functionality with real-world applied data, in this case the health workforce capability of rural health professionals. Our findings confirm that these techniques can be used to develop a future prototype of an app that may assist health professionals in improving or maintaining their health workforce capability, which in turn may increase recruitment and retention in rural areas. Health professionals need to be central during the design phase. Interventions are needed to provide a supportive environment to rural and remote health professionals to increase their rural health workforce capability.