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The CEO and CMO of SidekickHealth give a deep, detailed look at the development and potential of mobile apps that could change how patients approach their chronic conditions.
Doctors have all had the lifestyle change talk, probably thousands of times.
We’re treating a patient with a lifestyle disease — obesity, hypertension, prediabetes. We assess the patient, evaluate treatment options and recommend a plan of care. Typically, this guidance amounts to better diet, more physical activity and less stress.
It’s a completely rational course of action. It’s the right approach to living healthier. But it just doesn’t take hold.
We distinctly recall instances of the lifestyle change talk with patients. Once, a middle-aged man recovering from a heart attack came in for an appointment. He seemed to understand the gravity of the situation, received evidence-based guidance delivered in a traditional way, and then was seen outside the clinic lighting a cigarette. On another occasion, a 60-year old woman was admitted to the hospital with high blood pressure. Because the traditional lifestyle change talk wasn’t working for her, the best treatment plan was to prescribe her an antihypertension drug… when she was already taking two.
We were trying to put out fires we would have liked to prevent, and we knew there had to be a better way. After years of research with leading universities and institutions and many real-world examples, we think we’ve found it.
The Dual Rise of Diseases and Devices
Chronic lifestyle-related diseases account for about 70 percent of deaths and up to 80 percent of health care costs worldwide. In 2014, diabetes affected 422 million people, and the trend continues on an upward trajectory. About one in three adults in the U.S. and the UK has prediabetes, increasing risk of heart attack, stroke, and type 2 diabetes. These diseases pose an escalating threat to global health and wellbeing.
At the same time, mobile devices have seen explosive growth and use. Not only are they widely distributed, but people carry them constantly, spending several hours per day using smartphone apps. As such, mobile devices can potentially increase provider-patient interaction during lifestyle interventions, as well as offer an avenue for primary prevention.
At a time where we need to flip the trend of lifestyle diseases, we have a ubiquitous, adaptive vehicle to tailor behavioral interventions to patients. But we still need to make those interventions more effective.
A new approach: Finding the triggers for lifestyle choices
To slow the lifestyle disease epidemic, we have to re-think how we think. The approach we’re taught in medical school — the takeaway from “the talk” – isn’t wrong. It’s all in the delivery.
The field of behavioral economics combines lessons from psychology and economics to investigate how individuals actually behave, as opposed to how they would behave if they were perfectly rational, with unlimited willpower, and solely acting out of self-interest. It considers how people are influenced by their emotions, identity, environment and the framing of the information.
Many lessons from behavioral economics apply to public health because they help us understand why people make choices, and in turn, how to guide them towards better ones. In three years of research, we teamed with experts from Harvard, MIT, and more than two dozen professionals on both sides of the Atlantic to determine how these applications could be put into practice.
Effective Engagement to Change Behaviors
We hypothesized that a mobile health-engagement platform could significantly enhance a structured lifestyle change program. We integrated principles of behavioral economics, gaming technology, artificial intelligence, evidence-based guidelines and personal coaching. We combined our clinical expertise with a team of experienced game developers and launched SidekickHealth to prevent and manage lifestyle disease.
Seven concepts from behavioral economics serve as pillars for the platform.
1. “Fast thinking” controls most lifestyle choices
Behavioral research suggests two separate cognitive systems control our choices. Psychologist Daniel Kahneman describes them as fast thinking — which is intuitive, impulsive and emotionally charged – and slow thinking – which is rational, deliberate and reflective.
By targeting fast thinking, advertisers have been winning our hearts, minds and stomachs for years. The cartoon characters synonymous with breakfast cereals are examples of the food industry’s adept appeal. Public health organizations, on the other hand, typically target slow thinking. Just turn the cereal box over for a black and white label densely packed with nutrition information. There’s a lot of squinting at tiny print required for a rational, healthy choice.
To use fast thinking for good, we designed a gamified platform with colorful graphics, characters, competitions and instant gratification through rewards. The result is a highly engaging experience that enables patients of different health literacy levels, languages and ages to get and stay involved in the management of their health.
2.People use mental shortcuts, which can cause unhealthy behaviors
Studies indicate that lifestyle decisions, like how much to eat, are frequently biased toward an initial “anchor” value. For example, the quantities consumed at a meal are subconsciously cued by the size of plates and glasses. Referred to as “mindless eating,” this anchoring can increase how much people serve and consume.
3. Stress and cognitive demands may increase the use of fast thinking and adversely affect lifestyle choices
Human cognitive capacity has limits, and slow-thinking processes require significant effort and cognitive demand. To compensate, our brains often outsource lifestyle choices to our more impulsive, fast-thinking brain. The effects on our decision-making can be compounded when multitasking or stress are further straining cognitive resources.
To counter the effects of stress on lifestyle choices, we incorporate relaxation, meditation and mindfulness exercises into our platform as part of an evidence-based curriculum.
4. People tend to discount future costs and benefits, placing a higher value on the present
“Future discounting” works against health behaviors, which usually involve efforts in the present for benefits in an undetermined future (e.g., floss now to avoid a dentist visit later).
SidekickHealth provides opportunities for instant gratification, such as highlighting short-term benefits, promoting self-monitoring (e.g., dietary tracking, step counting, activity logging) and providing immediate feedback to users. We also employ commitment contracts to allow users to pre-commit to lifestyle changes, such as forfeiting soda or sweets, and to have a supporter, such as a coach or friend, for added accountability.
5. Framing health behavior as an enjoyable task, as opposed to an obligation, may positively influence behavior
The way healthy behaviors are presented to people can fundamentally alter their understanding of the experience. For example, Wansink and colleagues showed that study participants who exercised out of duty rewarded themselves with twice as much candy post-exercise than participants who received a message framing the exercise as an enjoyable nature walk.
In our gamified platform, we integrate messages that emphasize personal achievement, social interaction and fun to promote healthy behaviors. This approach can be especially effective with groups, such as a diabetes prevention program or a workplace wellness initiative.
6. Open channels may encourage some behaviors, while closed channels may inhibit others
“Channel factors” are the many small details that can have surprisingly large effects on people’s behavior. Examples that can lower the threshold for healthy choices include pre-slicing apples at a cafeteria (shown to increase apple sales), and making water more accessible by placing it at eye-level (shown to increase water sales).
We decided to open up channels for health improvement through a veritable “buffet” of options for improving diet, physical activity and stress reduction. Conversely, we avoid blocking channels by adhering to low health literacy guidelines and a visual design.
7. Behavioral economics models assume people are motivated by more than self-interest
Altruism is an important motivator for health-related behaviors like blood and organ donations, as well as many group- and peer-based interventions. Incentives benefitting our friends can also be several times more effective than standard individual incentives.
For completing health missions on our platform, users accumulate points. Over time, points earn them altruistic rewards in the form of clean water that is sent by charities to help children in need. Users’ earned points and rewards can also benefit their friends in the program.
Making it personal: The role of data
While behavioral economics powers our platform, we use big data and artificial intelligence to drive personalization. Each time a user chooses one of 120 different activities, SidekickHealth’s artificial neural networks learn from these behaviors to make intelligent future suggestions based on user profile and surroundings. Machine learning enables us to predict and present users with the choices that are most likely to activate them — boosting engagement and program retention much like Netflix’s curated suggestions increase viewer engagement.
Data is also important for the invaluable role clinicians and coaches supporting the patient’s path to better health. Through the platform’s care team portal, administrators can efficiently track participants’ activity, remotely send supportive messages and tailor instruction for in-person sessions.
Beyond promise: Results in weight loss, program adherence
Over the past year, the data-driven, gamified platform has been deployed to improve outcomes for in-person, community-based programs across the U.S., including those serving vulnerable populations at increased risk. Users were up to three times more likely to reach their five percent weight loss goals after 16 weeks, and they were up to 30 percent more likely to remain in the DPP for the full program. Similar results from a clinical trial were presented at the American Diabetes Association’s 77th Scientific Sessions in San Diego this June.
The use of images, games and smartphones overcomes the barriers to change otherwise attributed to social disparities and cultural differences. In a Los Angeles-based Medicare-age DPP where many people had never used an app, participants averaged seven exercises per day, with 84 percent retention at month four. A San Diego-based DPP with a Spanish-speaking cohort averaged six exercises per day, with 83 percent retention.
We have also seen success at scale with large employee wellness initiatives. For example, more than 2,000 municipal employees in Iceland’s capital participated in a three-week engagement program, completing 500,000 health-improving activities. Of the 700 who used SidekickHealth to complete a prediabetes screening, more than 200 were determined to be at risk and were referred to a lifestyle change program.
By understanding why people choose certain behaviors, we can help them choose healthier ones. By combining clinical and gaming expertise to make lifestyle change more engaging, we can help prevent and manage chronic disease. And by using technology, we can bring about the type of change that is needed at scale.
So now, in addition to having the talk with patients, we can empower them to walk the walk.