American Journal of Public Health Research
ISSN (Print): 2327-669X ISSN (Online): 2327-6703 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
American Journal of Public Health Research. 2014, 2(6), 232-238
DOI: 10.12691/ajphr-2-6-3
Open AccessArticle

Developing and Selecting Auditory Warnings for a Real-Time Behavioral Intervention

John Bellettiere1, , Suzanne C. Hughes1, Sandy Liles1, Marie Boman-Davis1, Neil E. Klepeis1, Elaine Blumberg1, Jeff Mills1, Vincent Berardi1, 2, Saori Obayashi1, T. Tracy Allen3 and Melbourne F. Hovell1

1Graduate School of Public Health, San Diego State University, San Diego, USA

2Computational Science Research Center, San Diego State University, San Diego, USA

3EME Systems LLC, Berkeley, USA

Pub. Date: November 24, 2014

Cite this paper:
John Bellettiere, Suzanne C. Hughes, Sandy Liles, Marie Boman-Davis, Neil E. Klepeis, Elaine Blumberg, Jeff Mills, Vincent Berardi, Saori Obayashi, T. Tracy Allen and Melbourne F. Hovell. Developing and Selecting Auditory Warnings for a Real-Time Behavioral Intervention. American Journal of Public Health Research. 2014; 2(6):232-238. doi: 10.12691/ajphr-2-6-3


Real-time sensing and computing technologies are increasingly used in the delivery of real-time health behavior interventions. Auditory signals play a critical role in many of these interventions, impacting not only behavioral response but also treatment adherence and participant retention. Yet, few behavioral interventions that employ auditory feedback report the characteristics of sounds used and even fewer design signals specifically for their intervention. This paper describes a four-step process used in developing and selecting auditory warnings for a behavioral trial designed to reduce indoor secondhand smoke exposure. In step one, relevant information was gathered from ergonomic and behavioral science literature to assist a panel of research assistants in developing criteria for intervention-specific auditory feedback. In step two, multiple sounds were identified through internet searches and modified in accordance with the developed criteria, and two sounds were selected that best met those criteria. In step three, a survey was conducted among 64 persons from the primary sampling frame of the larger behavioral trial to compare the relative aversiveness of sounds, determine respondents' reported behavioral reactions to those signals, and assess participant’s preference between sounds. In the final step, survey results were used to select the appropriate sound for auditory warnings. Ultimately, a single-tone pulse, 500 milliseconds (ms) in length that repeats every 270 ms for three cycles was chosen for the behavioral trial. The methods described herein represent one example of steps that can be followed to develop and select auditory feedback tailored for a given behavioral intervention.

real-time feedback warning sounds behavioral intervention auditory alerts immediate feedback auditory warning design alarm design

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Deiss D, Bolinder J, Riveline J-P, Battelino T, Bosi E, Tubiana-Rufi N, Kerr D, Phillip M: Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring.Diabetes Care 2006, 29: 2730-2.
[2]  Garg S, Zisser H, Schwartz S, Bailey T, Kaplan R, Ellis S, Javanovic L: Improvement in Glycemic Excursions With a Transcutaneous, Real-Time Continuous Glucose Sensor. 2006, 29: 44-50.
[3]  Dylos Corporation: Air Quality Monitoring Innovation [].
[4]  Klepeis NE, Hughes SC, Edwards RD, Allen T, Johnson M, Chowdhury Z, Smith KR, Boman-Davis M, Bellettiere J, Hovell MF: Promoting smoke-free homes: a novel behavioral intervention using real-time audio-visual feedback on airborne particle levels. PLoS One 2013, 8: e73251.
[5]  Wilson I, Semple S, Mills LM, Ritchie D, Shaw A, O’Donnell R, Bonella P, Turner S, Amos A: REFRESH--reducing families’ exposure to secondhand smoke in the home: a feasibility study.Tob Control 2013, 22:e8.
[6]  Gay V, Leijdekkers P: Around the clock personalized heart monitoring using smart phones. In Smart Homes and Beyond. Edited by Nugent C, Augusto JC. IOS Press; 2006: 82-89.
[7]  Tapia EM, Intille SS, Haskell W, Larson K, Wright J, King A, Friedman R: Real-time recognition of physical activities and their intensities using wireless accelerometers and a heart rate monitor. 2007 11th IEEE Int Symp Wearable Comput 2007: 1-4.
[8]  Edworthy J, Hellier E: Fewer but better auditory alarms will improve patient safety.Qual Saf Health Care 2005, 14: 212-5.
[9]  Reagan IJ, Bliss JP, Van Houten R, Hilton BW: The effects of external motivation and real-time automated feedback on speeding behavior in a naturalistic setting. Hum Factors 2013, 55: 218-230.
[10]  Wise J, Operario D: Use of electronic reminder devices to improve adherence to antiretroviral therapy: a systematic review.AIDS Patient Care STDS 2008, 22: 495-504.
[11]  Haas E, Edworthy J: An introduction to auditory warnings and alarms. In Handb Warn. 1 edition. Edited by Wogalter MS. CRC Press; 2006:189-198.
[12]  Hovell MF, Hughes SC: The behavioral ecology of secondhand smoke exposure: a pathway to complete tobacco control.Nicotine Tob Res 2009, 11: 1254-64.
[13]  Glazener C, Evans J, Peto R: Alarm interventions for nocturnal enuresis in children. Evidence-Based Child Heal A Cochrane Rev J 2006, 1: 9-97.
[14]  Hurkmans HL, Bussmann JB, Benda E, Verhaar J a, Stam HJ: Effectiveness of audio feedback for partial weight-bearing in and outside the hospital: a randomized controlled trial.Arch Phys Med Rehabil 2012, 93: 565-70.
[15]  Lai DT, Cahill K, Qin Y, Tang J-L: Motivational interviewing for smoking cessation.Cochrane database Syst Rev Online 2010: CD006936.
[16]  Martino S, Carroll K, Ball S: Teaching, monitoring, and evaluating motivational interviewing practice. Prof Motiv interviewing Pract 2007.
[17]  Rubak S, Sandbaek A, Lauritzen T, Christensen B: Motivational interviewing: a systematic review and meta-analysis.Br J Gen Pract 2005, 55: 305-12.
[18]  Edworthy J: The design and implementation of non-verbal auditory warnings. Appl Ergon 1994, 25: 202-210.
[19]  Johnston JM: Punishment of human behavior.Am Psychol 1972, 27:1033-54.
[20]  Lerman DC, Vorndran CM: On the status of knowledge for using punishment implications for treating behavior disorders.J Appl Behav Anal 2002, 35: 431-64.
[21]  Biding T, Lind G: Intelligent Speed Adaptation (ISA): Results of Large-Scale Trials in Borlänge, Lidköping, Lund and Umeå during the Period 1999–2002. Borlänge, Sweden; 2002.
[22]  Edworthy J, Stanton N: A user-centered approach to the design and evaluation of auditory warning signals: 1. Methodology. Ergonomics 1995, 38: 2262-2280.
[23]  Hovell MF, Wahlgren DR, Gehrman CA: The behavioral ecological model: integrating public health and behavioral science. In Emerg Theor Heal Promot Pract Res Strateg Improv Public Heal. Edited by DiClemente RJ. San Francisco: Jossey-Bass, Inc.; 2002: 347-385.
[24]  Patterson RD: Warning sounds in the work environment [and discussion]. Philos Trans R Soc London Ser B Biol Sci 1990, 327: 485-492.
[25]  Patterson R: Guidelines for auditory warning systems on civil aircraft. In CAA Pap 82017. London, UK: Civil Aviation Authority; 1982.
[26]  Hellier EJ, Edworthy J, Dennis I: Improving auditory warning design: quantifying and predicting the effects of different warning parameters on perceived urgency.Hum Factors 1993, 35: 693-706.
[27]  Suied C, Susini P, McAdams S: Evaluating warning sound urgency with reaction times.J Exp Psychol Appl 2008, 14: 201-12.
[28]  Edworthy J, Loxley S, Dennis I: Improving auditory warning design: relationship between warning sound parameters and perceived urgency.Hum Factors 1991, 33: 205-31.
[29]  Azrin NH: Some effects of noise on human behavior.J Exp Anal Behav 1958, 1: 183-200.
[30]  Reed P, Yoshino T: The effect of response-dependent tones on the acquisition of concurrent behavior in rats. Learn Motiv 2001, 32: 255-273.
[31]  Audacity Team: Audacity version 2.0.3. 2012.
[32]  Guillaume A: Intelligent auditory alarms. In Sonification Handb. Edited by Hermann T, Hunt A, Neuhoff JG. Berlin, Germany: Logos Publishing House; 2011: 493-508.
[33]  Rovniak LS, Hovell MF, Wojcik JR, Winett R A, Martinez-Donate AP: Enhancing theoretical fidelity: an e-mail-based walking program demonstration. Am J Health Promot 2005, 20: 85-95.
[34]  Hovell MF (PI): Innovation for Smoke-Free Homes: Real-Time Feedback Study. Supported by grant # R01 HL103684-02 from the National Heart, Lung, Blood Institute, NIH.