The art (or science) of persuasion in healthcare
Can the same techniques that glue us to our phones help us lead healthier lives?
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Let’s get to it…
🤷♂️ Problem
Problem 1: Poor health behaviours eventually lead to physical and mental health problems
An example from the King’s Fund -> Obesity reduces life expectancy by 10 years, costs the English economy £15.8B, and the NHS £4.2B
Problem 2: Forming good habits is hard. Improved health behaviours are often not maintained.
Participants in both weight loss and healthy eating programmes will often return to their prior behaviours after showing initial improvements
💡 Solution
Social platforms have been ruthlessly scientific in their approach to figuring out how to keep us using their products
They optimise for user engagement and lead to habitual behaviour. So how can we use similar methods to create products that optimise for better health outcomes?
Identify a problematic health behaviour, pick a behaviour change technique, use it to form a health protective habit, measure the improvement (or lack of) in health outcomes.
📖 Terms
Behaviour change theories - ways of explaining how and why behaviours change. Some examples:
The social cognitive theory - people will replicate the actions and behaviours of others
Trans-theoretical model - includes the ‘stages of change’ which describe how an individual contemplates, prepares, actions and (hopefully) maintains a new behaviour
Self-determination theory - the interconnection between internal factors (motivation) and external factor (an individuals’ environment) on behaviour change
Motivational interviewing - a counselling approach to elicit behaviour change
Behaviour change techniques - the actual tools drawn from the theories (👆) that drive behaviour change. Examples include:
Behaviour change techniques taxonomy (BCT) - comprehensive taxonomy of 96 techniques clustered into 16 groups
Behaviour change wheel (BCW) - focuses on someone’s capability, opportunity, and motivation for BC (the COM-B model) - interventions and policies are built around this
Behavioural change support system (BCSS)- an information system designed to facilitate BC without using deception, coercion or inducements
📚 History
Behaviour change in digital health has it’s origins in ‘persuasive technology’:
BJ Fogg was a pioneer in the field of persuasive technology, establishing the Stanford Persuasive Tech Lab in 1998 and setting the foundation for the field of BC
Harri Oinas-Kukkonen and Marja Harjumaa built on persuasive technology to coin ‘persuasive systems’ - computerised software or information systems designed to reinforce, change or shape attitudes or behaviours without using coercion or deception
Recognising the opportunities for building software applications targeted for behavioural change, Oinas-Kukkonen established ‘Behaviour Change Support Systems’ which set out a framework for behavioural interventions
Since 2010 with the introduction of the smartphone, the number of publications in the field of behaviour change has grown significantly. In the realm of health, research is starting to show effectiveness at the individual, community and population level
💼 Use cases
Mental health (see below)
👥 Players
Changing Health - platform combining health psychology and data science, focussing currently on HbA1c and weight reduction in diabetics
Noom - CBT based coaching to help enact behaviour change for weight loss
DNANudge - DNA analysis + wearable + phone app to encourage better food choices guided by the user’s genetics
Fitocracy - mobile app that uses community, coaching and gamification to encourage better fitness and eating habits
Daylio - mood diary and tracker for self-care insights
Ten Percent Happier - meditation app that uses planning to keep people accountable
QuitGenius - behaviour change platform for smoking and other addictions
🔮 Predictions
Behaviour change platforms with a strong enough evidence base will get baked into clinical guidelines and become a routine feature in chronic disease management
Successful BC companies will focus on the individual’s wellbeing - recognising that an individual’s positive feelings and functioning in life are just as important for persistent behaviour change as improvements in HbA1c
Increased experience of remote/tele-healthcare during COVID-19 will encourage the uptake of digital BC tools
Future products will explore a wider range of BC tools beyond the current narrow focus. Of the 96 techniques described in the BCT - only a relatively small number are commonly used
Behaviour change based around stigma will fail to help the people those tools intend to help the most
🌅 Opportunities
Gamification - increasingly used as a paradigm for developing persuasive systems
Channels - different interventions require different channels (app, web, wearable, SMS) in order to be effective
Collaboration - Interdisciplinary collaboration within BC is not widespread but could lead to more effective products. Founders who want to deploy BC need to consult with the specialists in the field
Persistence - Many current interventions do not maintain BC in the long term. Future products need to be more sticky and have impacts that can be measured over years and not just months
Digital literacy - Behaviour change products need to bring along the digitally illiterate or risk leaving behind those who require BC interventions the most
Evaluation - Better implementation of behaviour change techniques using a consistent approach to evaluate their impact
🔗 Links
Why Behaviour Change Apps Fail to Change Behaviour - a short essay by Nir Eyal which introduces a couple of interesting concepts (‘haftas’ and ‘wannas’)
Digital Health Behavior Change Technology: Bibliometric and Scoping Review of Two Decades of Research - A 2019 paper exploring the trend and patterns in digital behaviour change technology
An evaluation of behaviour change techniques in health and lifestyle mobile applications - a 2018 paper evaluating the most prominent BC techniques used in health apps
Using Health and Well-Being Apps for Behavior Change: A Systematic Search and Rating of Apps - a 2019 paper that uses ABACUS - a new scale designed to rate the BC capability of apps
Thanks for reading, see you next week 👋
Sandy