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Beyond the App – a novel take on personalizing digital health can increase its effectiveness

7 Oct, 16 | by BMJ Clinical Evidence

talya-miron-shatz_croppedBy Talya Miron-Shatz

As a health professional, you know that digital health tools, such as wearables and apps, abound. You hope these help patients adhere to medication, monitor their blood pressure, manage their diet and other treatment, maintenance and prevention tasks which take place outside of the clinical encounter, and have an effect on health outcomes. You also know that these tools are not always effective. In fact, a systematic review found that only 39% of randomized control trials using mobile health to promote adherence to medication reported significant improvements between groups.

The questions you want answered are: what makes a digital health tool comprehensible, engaging, motivation-instilling, and leading to a sustainable behaviour change and health improvement? These are the same questions I ask, both as a researcher, and in my industry work with startups, corporations, health advertisers and pharmaceutical companies, all aiming to create compelling patient-oriented digital health tools.
Granted, if the only tool you have is a hammer, you are tempted to treat everything as if it were a nail. I’m a social psychologist, so to me, the answers to ‘what makes digital health effective?’ go beyond the obvious technological answers of measuring and monitoring. It is up to psychology to help digital health tools to truly predispose and enable behaviour change which will support the clinical practice.

An elegant example of predisposing comes from Canada, where researchers created an app for adolescents with Type 1 diabetes, which shows users where their blood sugar level will be within a few days, should their current measurement trend persist. This follows a recommendation on turning big data into small data, which patients can in turn make sense of, and use to improve their health.

The app asks patients how their measurement values got there: time for confessing to nutrition and exercise vices. Then – what they are going to do about it, rendering the patient the creator of her improvement plan. She alone knows whether she’ll abstain from French fries, swim a few extra laps, or walk to school instead of taking the bus. This epitomizes what I refer to as ‘beyond the app’: connecting the numbers on the iPhone, tablet, android or computer screen with real life behaviour, and predisposing the change in a way that is personalized, and self-related. Note that this is also a skinny, if effective, form of supportive accountability.

The example for enabling change is an old-school type of elegant. With German researchers, we approached coronary heart disease patients (mean age 73.8), who had no prior experience with smartphones or tablets, and gave them each a tablet with the ‘medication adherence’ app. For a month at a time they used the app, and (in randomized order) used a pen and paper adherence journal. Their subjective and objectively measured adherence to medication and to blood pressure measurements increased significantly more following the tablet intervention, when compared to the pen and paper one. Almost all patients preferred the app it to the pen and paper journal, were satisfied with the app, and wanted to keep on using it.

This is a hopeful message for anyone wishing to integrate digital health tools in their practice, comprising patients of all ages. So, how did we miraculously overcome the digital divide in this population? By going beyond the app. We did not just create a digital health tool and expected these elderly, non-tech-savvy patients to familiarize themselves with it and learn how to master it. That would have been a miracle. Instead, an investigator visited each patient, giving them the tablet, demonstrating, and entering their medication regimen details. All other applications were hidden on the tablet, and its sleek ‘on’ button was covered with a large green sticker that spelled ‘on’. These seemingly technical steps are rooted in the psychology of elderly patients, who may feel anxious over using the unfamiliar technology and perhaps avoid it altogether.

Digital health can indeed make good on its promise of scalable, affordable, and easily accessible health improvement, thereby becoming an indispensable instrument in the virtual black leather bag physicians carry. But, for this to happen, psychology must play a larger role. Predisposing and enabling behaviour change seems to provide a turning point for digital health, leading to an increase in better health outcomes.

Talya Miron-Shatz is Associate Professor and Founding Director of the center for Medical Decision Making at the Ono Academic College, Israel, and a Senior Fellow at the Center for Medicine in the Public Interest, New York. She is CEO of CureMyWay, a consulting firm for behavior change in health. Her Psychology Today blog Baffled by Numbers deals with medical decision making, and she is currently writing Heads or Hearts – How We Really Make Medical Decisions.

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