At my internship I was fortunate enough to get the opportunity to help my supervisor, Hanna, with the writing of the following blog post. You can view the original post on the Tobias & Tobias blog here.
There is an emerging sector that combines healthcare with technology, attempting to assist in lifestyle choices to improve the management of chronic conditions like diabetes or habits like smoking. Human beings hate to change established behaviour. Even when our health is at risk we refuse to change our ways because we think we know better than what the evidence suggests. Many of us struggle to change our behaviour or simply do not attempt to at all.
Despite the illogical nature of this, it seems to be universal and very hard to crack. In addition to the difficulties we have in changing habits, we are often also bad at receiving criticism and often lack the necessary self-discipline to live a healthier lifestyle. Any of these issues (which can sometimes occur in combination) makes changing a person’s behaviour a very difficult task.
The academic study of how to change people’s behavior is a relatively new field, with roots in cognitive psychology, physiology and neurology. Behaviour change scientists are honest about the infancy of their discipline. At this point in the discipline temporary change, incremental change, and attitudinal shifts are considered as valuable as wholesale alterations.
The doctor can see you now
In recent years, there has been a rapid increase in the ability to closely monitor the health of an individual without having a significant impact on their personal freedoms. This has led to huge changes in the delivery of behaviour-reliant medicine. Patients can be monitored remotely and unobtrusively, yet accurately. Diabetics and asthma sufferers can record their blood sugar or oxygen levels and other relevant symptoms on the go without specialist equipment or time-consuming transcribing, overweight patients can scan the barcodes of products in the supermarket to discover if they are a recommended option, and those trying to cut down alcohol or cigarette consumption can measure their success (even against peers) as a way to motivate themselves to continue their improvement. There are interesting developments in adherence via technology.
However, there is no lack of support mechanisms available to paying customers to “assist” them in changing behaviour in return for health benefits. There are a large range of smoking cessation apps currently available that monitoring cost saving, days without smoking, oxygen levels, brain function and heart rate. These products and services have been purchased in the millions, creating a hugely profitable industry. The smoking cessation industry in isolation was valued at £136milion in 2013 . At the moment, there is very little evidence of their efficacy, or research backing up the methods they are using.
People want to reduce the level of responsibility and difficulty of changing their behaviour by purchasing products or services that assist them. The healthcare technology sector has an obvious cross-over point with the work of behaviour change scientists if they want to improve the reputation and scalability of their products and services. The health sector aims to keep people healthier, using methods proven by research and testing. Technology provides the opportunity to do so on a broad scale by putting the tools to manage health in the patient’s hands, with visibility for healthcare professionals like never before. And despite the relatively recent emergence of behaviour change science, we know one thing for sure: intervention is the key.
Building with an effective model
Those with a lifestyle-based issue such as smoking, drinking too much alcohol or being overweight are aware that they need to change their behaviour to solve their health issue, but habits are hard to break. They are even harder to break if no one is chastising or encouraging you. Many people will attempt to make their transition to a healthier lifestyle easier by purchasing assistive products or services, such as apps, recorded programmes or devices designed to discourage their ‘bad’ behaviour. The efficacy of these services is limited because there is not a link between the services built by the technology sector, and the theories of behaviour change proven in clinical research labs.
Behaviour change theory tells us unequivocally that there is a triumvirate of factors that must work together to create long lasting alteration of habits:
What science tells us
Essentially, current commercial models of behaviour change products and services do not do enough to effect change in the habits of their users. App developers build good looking and supportive software that is not sufficiently adherent to the COM-B model to keep their customers off the fags, or out of the cookie jar. Behaviour change theory tells us that in order to break habits, we need intervention on increasingly intrusive levels at key stages in the treatment in order to effectively maintain the new behaviour patterns. According to the COM-B model this intervention must come from three different angles.
1. Capability – the individual’s own will power to change their behaviour
2. Motivation – coming from the proper authority, in this case a doctor
3. Opportunity – this is where technology comes in to help consistently monitor and alert you of your behaviour change goals.
One element that behaviour change scientists are certain about is the ineffectiveness of a non-human intervention. If all you have is an app on your phone, you are highly unlikely to achieve sustained or significant results in your attempt to change your behaviour. At the very least, a multi-channel approach is necessary with peer group support, phone calls, face to face contact and emotional attachment. This cannot be replicated by digital interventions. Simply put, if you know no-one is actually watching, you won’t maintain difficult changes.
How technology can help
The following example shows a potential way that technology could increase one’s capability to change their behaviour through consistent, yet varied intervention.
If you are attempting to quit smoking, and you set up your app to know that a weak moment is your arrival at work, a simple notification from the app may deter you from having a cigarette for a few days, but you will swiftly prefer to ignore the notification as your cravings become harder to resist over time. At this stage, an increase in the intrusion level of the intervention is necessary; perhaps an alarm that requires manual intervention to switch it off, and later in your progress, a phone call with a real person may be the most effective way of preventing you from backsliding.
Throw money at the problem?
Money seems to be a problem at both ends of the development chain. Without sufficient clinical input, the efficacy of any product or service is severely limited, but proven research is unlikely to make the transition to market, because of a lack of exposure to the right commercial partners.
The technology sector is unlikely to have the resource to service this level of commitment to a product, and often has no inclination to seek better clinical partners due to lack of profitability of a truly effective service. The sad facts are that having a pleasant-to-use smoking cessation app that doesn’t really work is more profitable than creating one that actually works.
Regulations involving healthcare innovation also make it very difficult to implement new technology in the health sector. There are strict guidelines when it comes to manufacturing and distributing healthcare products to ensure the safety of patients who will eventually use these tools. New technology must not only be safe, but it also needs to be proven as both accurate and effective, and tested by differing standards across jurisdictions and state boundaries. This can greatly slow the process of integrating behaviour change technology into standard medical care no matter how much money is put behind it. As a result, many products go to market without the backing of the medical or clinical community, and simply rely on testimonial for their reputation.
The missing link
Often the barrier between good academic research and a successful commercial product is good design. Good clinicians are not concerned with creating a beautiful interface or thinking about how many clicks stand between the start and end of a journey through an app, just as good designers are not necessarily concerned with the importance of behaviour change methodologies. Hiring a designer is hard for a clinical researcher to justify, and hiring a medical specialist to check your methodologies is unrealistic for a designer. From the customer’s point of view, an unpleasant interface is often (falsely) equated with unreliability, untrustworthiness and in medical terms, quackery. The irony is that at the moment, the ‘poorly designed’ products are likely to be the ones with the best clinical or medical foundation.
The goal then, should be to bring these two sets of values together. Recently, Diabetes UK ran a campaign in the national press and on social media to highlight the increase in amputations linked to poor management of diabetes in the UK. The number is currently 135 a week. In a first world country, where access to healthcare is free and education levels are generally high this fact itself is staggering, but even so, is publicity of this statistic alone enough to motivate the people to change their behaviour? Diabetes UK urged its followers on Twitter to tweet at UK Health Secretary Jeremy Hunt using the hashtag #135Shoes. The intention is to create human intervention amongst patients with diabetes, to encourage better management of the condition without the need for costly medical intervention.
Bupa have partnered with UCL’s Centre for Behaviour Change to make that matching process easier. By working with some of the UK’s most advanced researchers in behaviour change, Bupa are putting themselves in the centre of healthcare innovation giving the private health insurance provider the chance to lead the way in use of emerging technologies, theory-based design, and effective intervention.
We were proud to be a part of the team that launched GLIDHE earlier this year, and continue to see huge potential in the partnership.
With the release of smartdevices, increasing capabilities in wearable technology and remote monitoring, healthcare will inevitably change significantly in the next five to ten years. The healthcare sector is already primed to include these devices in their offerings, despite the issues seen in other sectors with uptake and trust – e.g. the launch of Apple Pay in the UK was met with mixed reactions.
There are however some obstacles in incorporating new health technology. It is difficult for clinicians and designers to be on the same page when it comes to innovation. As the two fields grow closer together it is becoming more likely that wearable and smart devices will be used by the medical sector. If the decisionmakers in these two fields can manage to align their values and arrange funding there will be many potential benefits from the resulting partnerships. Innovators will be rewarded with multimillion pound contracts or buy-outs, the health of the richest will improve and choice will increase for those who measure their health as a score on a fitness app. For those in the developing world, changes will also be tangible – we have seen innovation allowing a regular text message to assist in the monitoring of high risk pregnancies, diabetes and glaucoma in our own work, and many other insightful and useful mechanisms for use by the poorest and most remote communities in the world.
By creating better links between healthcare providers and medical experts, the efficacy of intervention products and services will hopefully become more about improving people’s lives rather than profit margins.