Imagine you’re in the shoes of Bill, a type 2 diabetes patient. You’ve just left the doctor’s office, where you’ve told your PCP that things seem to be going pretty well. You are eating better, you are starting to take some short walks, and overall you feel pretty good. Your doctor seems happy about all of this, but your A1c is higher than he’d like, he tells you. He says you should pay more attention to things like carbs, and creating a balanced plate at meals. And you should exercise more, because the walks aren’t doing the trick.
What? You just told him that you’re eating well and you’re exercising. You feel let down as you leave the appointment. On your way out, the receptionist hands you a few pamphlets that your doctor wants you to take home and read.
You scan the titles: Eating Healthy with Diabetes, The Diabetes Diet, and Type 2 Diabetes and Exercise. You toss the pamphlets in the trash on your way to your car.
What just happened here? The short version is this: Bill goes to his quarterly appointment feeling energized and proud of the work he’s done caring for his diabetes, only to be told that what he’s doing isn’t enough, and he needs to do more to get tighter control of his numbers. His doctor hasn’t truly heard him, and is treating him like a number. On top of that, his provider gives him information-heavy, generic materials covering topics Bill already thought he was managing well. Bill leaves feeling defeated and annoyed with his doctor.
These well-intentioned informational materials typically get tossed aside for these reasons and others. In the research we’ve conducted with patients with chronic diseases, they’ve told us the number one quality they value in their doctors is their ability to listen. They want a doctor to hear their view point and take their position into consideration when coming up with an action plan. Patients want a management plan that reflects both their expertise (as the patient) and the doctor’s expertise. The complete opposite happened to Bill.
There are so many ways Bill’s scenario could be improved. Key tactics that could have a big impact on Bill’s situation include:
- Point of care tools delivered to his PCP to help him work with Bill to uncover his key behavioral drivers to change
- Trainings to help his PCP communicate more effectively and utilize appointment time more efficiently
- Behaviorally-based content provided to Bill to help him set personal goals that are of interest to him and that will help him work through his unique problems and obstacles
These kinds of personalized solutions allow us to reach an audience more effectively and promote positive change. They help facilitate better in-office communication between doctors and patients, which impacts how a patient views his or her condition and ultimately how it gets managed. And these solutions serve as extensions of the appointment, helping patients manage their conditions over the 3 or 4 months they are on their own between appointments.
It’s time to rethink how we’re educating our patients and truly begin energizing them to take an active role in their care.(Read full post)
Last week our behavioral and creative teams had the privilege of receiving a 1-day health coach training from experts at the UNC-Greensboro Department of Public Health Education. This training was a unique opportunity to learn best practices when working with patients in the most intimate of settings: a health coaching session.
The dynamic day included an explanation of the 3 different styles of communication used in coaching: Directing, Guiding, and Following.
“Directing” takes place when the coach tells the patient what to do and the best way to do it. “Following”, on the other hand, has the coach openly listening with no agenda, and following along with whatever the patient wants to discuss. The “Guiding” style is when the coach affirms that the patient is capable, and works to increase the patient’s ability to change the desired behavior, guiding them through questions and conclusions rather than dictating them.
It was interesting to learn from this training that, though guiding may be favored in our changing healthcare environment, there is a time and place for each of the 3 styles of communication in talking with patients. There are times when, for the patient to understand the gravity of a diagnosis or necessity of treatment, the doctor should use the directive communication style. The patient needs to know exactly what to do and how important it is to do it. Other times following may be most appropriate, if the patient simply needs time to have their thoughts or concerns heard.
A big part of my internship with MicroMass this summer is working on a research project that looks at the trends in doctor/patient communication and how the way in which a doctor communicates with the patient may bring about different patient outcomes. We’re currently fielding the study, and are eager to learn more about the doctor/patient relationship from people living with chronic disease. Of particular interest is learning how these different coaching styles are being used in real-world situations and how they may impact both positive and negative outcomes.
The question is –which style is most beneficial when? And how can the healthcare provider figure that out in at any given moment? We are looking forward to seeing how the results of this study bring us one step closer to finding out.(Read full post)
Managing diabetes is complicated. You need a base understanding of what the disease is doing inside your body – how it behaves, what keeps it in check, and what it can do to you. Without this, you wouldn’t even know where to begin (or why you should want to manage it). You also have to be motivated. You have to believe management is within your control. Otherwise, what’s the point in even trying? You have to realize there are things you can do – however small – that can impact how it behaves. Lastly, you have to know what to do. You need to learn the skills to be able to manage it. You need to believe you can actually do it.
You might be asking yourself how people with diabetes get along with the disease. How do they manage the day-to-day demands placed on them? How do they make decisions that will help them be as healthy as possible? And the answer is that some people do manage the disease every day, taking it into consideration as they make choices for themselves. But others may deliberately ignore it, or may not even realize it’s something that requires their attention.
We know that close to 95% of diabetes management falls on the shoulders of patients, and we wanted to figure out a way to reach them where they are. Daily challenges come up that are difficult to manage. By building patients’ skills, we can help them take the actions necessary to most optimally manage their disease.
Patients are constantly on the go, so providing them with something that would not only accomplish the above disease management goals but also fit into a busy lifestyle was critical. Creating an app was the logical choice. When we looked at apps currently available, what we found were a lot of trackers and programs focused purely on information dissemination. What was missing was the behavioral component to help patients actually make and sustain the desired changes. Trackers are great for keeping logs of eating habits, exercise, and even blood glucose. But not much more.
And so the Time2Focus diabetes mobile app was born. We’re in the midst of putting the final touches on what will be a groundbreaking phone app to help patients with type 2 diabetes more successfully navigate the ins and outs of the disease, make educated and empowered decisions on a daily basis, and be able to work around real-world obstacles that stand in their way.
The 12-week program is grounded in the behavioral concept of problem solving. In simple terms, this is all about helping patients learn how to apply their own understanding of their diabetes to handle new situations that arise. It requires that patients not only understand their disease and learn key skills, but also are able to apply what they’ve learned to new diabetes-related situations that come up (which happen every day) so they can work around these new obstacles and stay on track.
We’re also using gamification principles to help keep patients motivated and engaged. We’ve designed challenges that not only test knowledge, but ask patients to rely on their new disease understanding and experiences to navigate obstacles. Patients are challenged to apply new concepts and make choices within the app that mimic real-world situations.
As the Time2Focus program development nears completion, we’re gearing up for a clinical trial to test its efficacy among over 100 people living with type 2 diabetes. Patients will spend 12 weeks participating in the program building their problem solving skills and ultimately making improvements in their diabetes health. In addition to behavioral outcome measures, we’ll also be measuring change in HbA1c.
Stay tuned for more details as the app continues to progress.(Read full post)
Yesterday, the NYT featured a story on the genetic testing of embryos to help ensure a deadly disease-causing gene would not get passed on to a couple’s unborn children. Having recently had a child myself, I can understand this family’s desire to protect their children from something that would likely cause suffering and premature death. The genetic testing process resulted in the birth of three children who are free of the gene. The comments run the gamut – some people praise the family for what they’ve done, but others question it. Some comments condemn the mother (who carries the gene) for being irresponsible for bringing children into the world knowing that there’s a good possibility she’ll die before they grow up.
The family indicated that they’ll share what the disease is all about with the kids and how it may affect their mother so that everyone is better prepared for what may happen in the future.
I found this interesting when looking at it from a behavioral perspective. There is clearly a lot of debate around whether or not it was ethical to hand-select embryos. I was even more interested in the thought process surrounding this woman’s choice to know whether or not she was a carrier of a gene that would likely cause early death. At the age of 26, she learned her fate.
How do you live knowing you might have just 5, 10, or maybe 20 healthy years to go? But on the flip side, how do you live as a 26 year old with the uncertainty of whether or not you only have a handful of good years left? How do you plan for the future?
As a behaviorist, this presents an interesting scenario. Knowing she was a carrier greatly increased this woman’s perceptions of control over so many aspects of her life. She felt like she was better able to make choices for herself and her family, feels like she’ll be better able to prepare her children to deal with what may come, and clearly values the need to set expectations for those around her.
Would you want to know whether you carried a gene like this? Would the control you gain from knowing this be empowering or paralyzing?(Read full post)
Did your parents ever forbid you from hanging out with that kid who was a “bad influence”? What about those friends who eat McDonald’s for every meal? Do people actually do that? And would you think of them as bad influences? You probably should. It turns out that poor health habits are contagious and may have decades-long implications.
We public health geeks call this social norming, or the effects of ones’ peers on their health. Bottom line: The people we surround ourselves with influence our environment, our behavior, and ultimately our health.
For those of us who like to look at the upside of social networks, determinants of health, the combined influence of our interpersonal, community, and ecological environments on our… Maybe this is really just me. In any case, I am happy to hear that people who are healthy tend to encourage their friends to keep healthy habits.
Personally, I am stretched to fit in either social or physical activity time into my busy schedule of nerding out at MMC and trying to keep my life together at home. My similarly strapped friends and I have a solution: A bi-weekly activity-based meet up. By changing up the typical dinner-and-drinks social routine, we hope to encourage and motivate each other to get moving, while still giving us a chance to catch up.
So far our ideas include beach volleyball, tennis, and swimming… Last week we went for a looooooong walk. We may have followed it up with a taco binge, but hey, at least we’re trying!(Read full post)
The goal of game mechanics and game dynamics is to drive a user-desired behavior predictably. The same ideas apply to human health behavior and the application of behavioral models and frameworks in health intervention design. This requires an understanding of how humans behave. This is where all those behavior models come into play.
There are many such models and frameworks, each useful in specific contexts. A model/framework is chosen based on whether it can give us the understanding we need to address the particular problem. Specifically to game dynamics and game mechanics, we can use the multi-factor model behavior model by J. Fogg of Stanford University known as Fogg’s behavior model (FBM). FBM asserts that there are three required factors that underlie any human behavior:
- Motivation (the want or desire to do something )
- Ability (the necessary resources)
- Trigger (the ‘spark,’ ‘signal,’ or ‘facilitator’)
According to FBM, these factors must converge at the same time to successfully drive a behavior. Any temporal misalignment in these three factors will degrade effectiveness. FBM also asserts that for the target behavior to happen, users usually require a minimum level of ability and motivation called the activation threshold for the behavior. When the trigger (something that prompts or tells the users to carry out the target behavior now) is introduced at the right time (above the activation threshold), the user is lead to the inception of the predictable behavior.
Of course, more than one behavior model or framework can be applied to a health intervention. For example, we can leverage the Power Law of Practice into a task-based intervention. The Power Law of Practice states that people make fewer errors and are faster with the more time they spend doing the task. About 80% of improvement along the power function comes from figuring out a good strategy for getting the task done, while about 20% of improvement comes from getting better at the same strategy.
There is good evidence that the steep part of the power function is actually composed of a combination of step functions where each step is a learning event – where one acquires new knowledge or develops a better model for how the system works. An intervention designer needs to understand what learning events occur so that individuals don’t get stuck and stop using the technology or some of its features.
From a motivation perspective, we can utilize a model by Daniel Pink. Pink hypothesizes that in the modern society where the lower levels of the Maslow’s hierarchy are more or less satisfied, people become more and more motivated by other intrinsic motivators, specifically: autonomy, mastery and purpose. From a game dynamics perspective, purpose is satisfied by quests, discovery, epic meaning; mastery is satisfied by points, progression and levels.
As you can see, when the appropriate behavior models and frameworks are applied a health intervention, behavior change can occur in a more effective and predictable manner.(Read full post)
Millions of people across the world are constantly looking for the answer to a longer and healthier life. Resolutions are made to go to the gym more often and eat healthier foods, and to spend more time with family and have a better work life balance. But at the end of the day, it’s tough to make all of these changes. We’re constantly stressed by family and work commitments and the daily struggle to make time for competing demands. So how do the people living in Blue Zones, those areas of the world where people have been found to live the longest and happiest lives, make this happen amidst the normal stress of daily life?
Dan Buettner, the author of The Blue Zones: Lessons for Living Longer From the People Who’ve Lived the Longest, outlines nine commonalities found among those people living in the five Blue Zones that have been identified as those areas of the world where people live the longest. And a January 9, 2013 article on this topic provides a nice summary of these nine “secrets” to living a long life. I’ve included them below for consideration. For more details, you can visit Dan Beuttner’s Blue Zones website.
1. Move naturally: The world’s healthiest and longest-living people don’t run marathons, nor do they go to the gym. Their body is the gym, and life is a workout.
2. Purpose: Know and live your life with purpose.
3. Downshift: Stress leads to chronic inflammation, which is associated with every major disease. Cultivate daily rituals and strategies for managing stress. Prayer, mediation and naps are among “Blue Zone” techniques.
4. The 80 Percent Rule: Stop eating when you’re 80 percent full. Don’t snack all day. Eat your smallest meal in the evening.
5. Plant slant: Eat a more plant-based diet with lots of beans. Have just 3 ounces of meat about five times a month.
6. Drink a little vino: That’s one to two glasses – 3-ounce glasses, that is!
7. Belong: Faith-based communities play a big part of Blue Zone lifestyles. According to the research, participating in a faith-based community four times a month adds 4 to 14 years to your life.
8. Loved ones first: Put family first. Blue Zoners have committed relationships, investing time and love with their children and their aging parents. Sorry, no nannies and no nursing homes.
9. It takes a tribe: Blue Zone communities share and support healthy lifestyle behaviors, and these values are passed on to subsequent generations.
These don’t seem so difficult upon first reading them, but really if they were that easy, we’d all live to 100!(Read full post)
Dr. Charlene Quinn, from the NIH’s Office of Behavioral and Social Sciences Research, put it this way in her recent spotlight video (you can watch below) concerning mHealth in diabetes management: “There are thousands of applications calling themselves mobile health, but very few of those applications actually have science behind them…”, which includes the clinical data, the evidence, they actually work. She concludes by saying: “We really need to think through not only data and numbers, but what behaviors, using mobile health or mobile technologies, most encourages people to change their behavior, improve their health, and ideally improve the health of a population.”
That got me to thinking about what fundamental characteristics that an mHealth intervention needs to have to be successful in changing a patient’s behavior. Many of these characteristics are simply good design principles: understanding the patient, knowing the socio-ecological system and sub-systems, iterative design and implementation. In general, simple messages delivered at the right time in the right place that are tailored, non-disruptive and repetitive and consistent is a sound way to think of how to build an mHealth intervention. The nature of portable computing with mHealth gives us the right place (where the patient is). Characteristics for a behaviorally-based mHealth intervention also require the ability to detect points of decision, behavior, and consequence and mobile devices require attention to interface design.
One important thing to consider is that sensors sometimes lose contact or run out of power or the wireless network is interrupted. Additionally, patients may willfully disable senor devices or not log the data or be as truthful as they should. What then? Statistics can play a big role with imputation techniques (procedures are designed to fill in the missing data gaps), but there can be legal, privacy and medical issues and is a topic for another day.
So as we think about both the advantages of mHealth (ability to observe multiple and repeated levels of behavior as it happens in naturalistic settings) we must also consider some of the issues (missing data, good user experiences, privacy, etc.) as well.(Read full post)
It’s December. That means in just one month it will be a new year. And with a new year comes the ever popular New Year’s resolution. Whether it’s to stop biting your nails, exercise more, eat healthier food, or spend less money on clothes and shoes you don’t really need, it’s a commitment you’re making. And as we all know, just because you make a commitment doesn’t mean you’ll keep it. In fact, Dr. John Norcross, a psychology professor at the University of Scranton, indicates that only 40% to 46% of “New Year’s resolvers” will actually be successful after six months. That means more than 50% of those who desire to make changes won’t achieve success.
If you do plan to participate in this popular New Year’s activity, try to make an effort to set achievable and realistic goals for yourself. You can do this by setting SMART goals. These are goals that are specific, measurable, attainable, relevant, and timely.
For example, If you’re interested in exercising more, your goal shouldn’t just be, “In 2013, my goal is to exercise more.” Instead, include additional details that are not only realistic for you given your schedule and desire, but also measurable. An example of a SMART goal is, “In 2013, I will go to the gym 4 days a week for 45 minutes each day.” And don’t be afraid to adjust your goal if you find it’s too lofty. Sometimes schedules can get in the way. This doesn’t mean you should give up. It just means you need to make some changes so that you’re working towards something more feasible.
This year, in addition to breaking that nail biting habit, make a commitment to fall into that select group of 46% that is successful.(Read full post)
Take Two Apps and Call Me in the Morning
It may not be too long in our future when part of a prescription from our physicians may include and app (or two). This is the exciting idea of medically prescribed apps. Some futurists predict that doctors will prescribe FDA-approved apps to treat patients. So far, the FDA has maintained that it will only vet apps that perform device-like functions, such as making diagnostic determinations or treating ailments. The FDA has yet to release its full guidance on the regulation of mobile apps and will not go after the many available downloads that make untested medicinal claims until its rules are in place.
WellDoc is one of the pioneers in the prescription-app field. Its DiabetesManager system collects biometrics about a patient’s diet, blood sugar levels and medication regimen through manual input or from wireless devices. It then gives advice to a patient and sends clinical recommendations to the doctor. The Food and Drug Administration gave the system 510(k) clearance to operate as a medical device in 2010.
Happtique (health app boutique) is a company that operates a mobile app prescribing solution for healthcare called mRx. Happtique has recently launched a pilot that will test whether the company’s solution will encourage doctors to prescribe mobile software for patient use. mRx consists of Apple and Android smartphone and tablet compatible apps that focus on cardiology, rheumatology, endocrinology, orthopaedics, physical therapy and fitness training. The mRX system gives patients more structured guidance when it comes to selecting and using health apps and empowers them with tools to help them take a more active role in their care. And similar to traditional prescription, mRx will track how many times an app is prescribed as well as how many times patients click the “fill” button once the prescription is sent.
If the mRx trial is successful, it will help demonstrate that mHealth technology will be viewed as legitimate, powerful healthcare tools, not just fun programs to install on a phone or tablet.
From a behavioral point of view, the WellDoc and mRx systems can help encourage a dialogue between physicians and patients about available healthcare technology tools. These conversations will not only give patients additional resources, but will also encourage them to consider incorporating apps and other healthcare technology into their health management. In addition to increased health care provider connectedness, these systems also help achieve behavioral change and continued adherence through sustained influence over the patient’s multiple chronic states and enhanced patient self-determination.
When you think about it, these apps are no different from physicians prescribing a diet, a support group or any other resource. In fact, these apps will enable physicians to be more creative with the ways they engage their patients and provide the best care to them.(Read full post)