Being a GP at a public health conference is, I imagine, like being a proctologist at a plumbers’ convention: familiar subject matter, different perspective. I spend a lot of my clinical time advising people about smoking, alcohol, healthy eating, weight loss, mental health, contraception—all sorts of things that have at their core the vagaries of human behaviour—but I’m not sure I do it very well. A tidal wave of long term conditions is flooding the NHS, and I’m always interested to know what new tricks the population health approach has to address these.
Digital health was a key theme at Public Health England’s (PHE) annual conference last week, with several sessions highlighting its partnership with behavioural science to influence health behaviours.
Nudge: the influence of “choice architecture” on health behaviours
Coined by Thaler and Sunstein in their 2008 behavioural economics bestseller Nudge: Improving Decisions about Health, Wealth, and Happiness, the term “choice architecture” means designing the context in which people make decisions. As the architect making small, but deliberate, changes to a person’s environment, you are “nudging” them to choose a certain action, without taking away their freedom of choice. Choice architecture can help people make healthy decisions, explained Liz Castle from PHE’s Behavioural Insights team using some clever examples below.
Imagine you’re having a day out in London. You use the Underground. There are two ascending escalators and a set of stairs. If one of the escalators is stationary, you are more likely to use the stairs than if both were working. Next, you decide to stop for a coffee. Coffee shops report that if presented with three cup sizes, you will tend to choose the middle one. Even if the size of all three cups is reduced, you will still tend to choose the middle one, not necessarily realising that you are getting less coffee for your buck. The list of “nudges” goes on. Painting a multi-coloured pattern onto a school playground will induce kids to run about on it. Removing confectionery from the checkout area of a grocery store will decrease its consumption. In fact, behaviour science became so influential that the UK government got wind of it, and set up their own behavioural insights team (also known as the “Nudge Unit”), which was tasked with applying behavioural science to various aspects of public life and services.
Social versus commercial marketing
Commercial marketing influences consumer behaviour in order to sell products. Social marketing uses commercial marketing principles to influence behaviour, but to benefit the target audience and society rather than the marketer. Both methods focus on the person, rather than the product. They focus on our instincts, desires, and aversions, which often lie unconscious in the deepest recesses of our brains, stirred to action by the promise of some momentary pleasure or the teasing call of a “buy one get one free.”
In an entertaining lecture, Rory Sutherland, a stalwart of the British advertising industry, told us that public health social marketing should not consider its techniques inferior to those used in commercial marketing. But he seemed to suggest that we’re missing a trick. He used the example of religious rules, which people have an uncanny knack of being able to follow blindly; these are usually binary: you must or must not do something. The rules are clear. Health related ones often aren’t. He has a point. Just think about saturated vs. unsaturated fat. Or alcohol in pregnancy. Or electronic cigarettes. Most people don’t think in nuance; they want an answer, and one they can relate to. While this is serious food for thought, there can be dangers to polarised thinking and, of course, it’s easier to be binary when you’re happy to be flexible with the truth.
Digital technology in behaviour change
So where does digital technology fit into all this? Over 80% of the UK population uses smartphones and this trend is growing, said Andy Wilkins of Transform UK. We check our phones, on average, 150 times a day. Our health behaviours are embedded in our daily rhythms and habits; now, our mobile phones are at hand to capture this information via digital health products such as apps, which can then be used to influence change by applying behavioural science.
According to Professor Susan Michie from UCL, digital interventions no longer merely deliver static information to the user; they can be real time, interactive, adaptive, and engaging. They can also generate a huge amount of data about us and those around us, using technology such as wearables, Bluetooth, and sensors.
Big Data or Big Brother?
While your phone or wristband may move about with you, it is in your home that your lifestyle is most firmly entrenched—your weekly sedentary sugar binge while watching Bake Off hidden away from public scrutiny. But now, amazingly, these influences on your health—how much you move, sleep, eat, and drink, even the air quality in your rooms—can be monitored.
Professor Ian Craddock from Bristol University talked about SPHERE, a community of researchers who have developed an experimental “smart” home that uses sensors, cameras, and wearable technology to try to track its occupants’ health. The idea is that, much like a nagging spouse, the smart home will build up a picture of your health behaviours over time and feed them back to you, in order to “nudge” you towards change. All at a cost of about £4000. In the trial evaluation, we were told, the end users found the intrusion “negligible or zero,” although questions still exist about privacy and desirability. Orwell might be turning in his grave, but at least now someone can tell us for sure.
When it comes to digital health we seem to have the technology, along with a wealth of behavioural science to draw on, but not quite the methods or outcomes—yet. It’s a space to watch, and an exciting one. My next blog (part two) will talk more about health apps, the challenges facing digital health interventions, and what PHE is doing about it.
With thanks to all the speakers for the opportunity to hear about digital health. The interpretations and views expressed here are my own.
Suchita Shah (@SuchitaShahUK) is a portfolio GP in Oxford, UK. She also holds degrees in public health and international relations. Her professional interests include general practice, public health, global health, medical education, writing, editing, photography, and the arts.
Competing interests: Nothing further to declare.