A Role for Continuous Technology-Enabled Interventions
[Editor’s note: the following is a summary of remarks given by Karen Calfas, one of more than 20 presenters at October’s sustainable behavior change conference, Consumer-Centric Health: Models for Change ’11. View a video clip of Calfas’ presentation on Health Innoventions video channel.]
University of California at San Diego health psychologist, Karen Calfas, Ph.D., explained that the key to driving successful maintenance of behavior change is by employing four components: ubiquitous technology; theory-informed, but user-relevant interventions; high degree of tailoring; and continuous interventions. Calfas has a long history of conducting research using tech-enabled interventions from a study using text messaging to improve diet (mDiet) in the early 2000’s to current project, SMART, that uses mobile apps and Facebook for weight loss among young adults. However, “technology components are no substitution for the human interaction,” says Calfas, “and they need to be thought of as ways to enhance it, ways to make it scalable and more accessible.”
Similar to Vic Strecher’s earlier comments, Calfas described the role of theory as a guide to inform, rather than dictate the design of interventions. “In the end,” stated Calfas, “they [interventions] need to be something that is meaningful to the receiver of it, and if she doesn’t see the meaning and component, then she won’t use it.” Calfas also advocated for personalized approaches by connecting interventions to the patient’s personal values and mission, among other more individual factors. Calfas stated that, ultimately, behavior maintenance results from people internalizing and finding more intrinsic rewards for the changes they are making.
However, cautioned Calfas, we may not be keeping interventions going long enough. “We should not be assuming that if we give patients a little dose of something, but then remove it,” articulated Calfas, “that they’ll be able to continue that [behavior] forever.” The key is doing continuous interventions, but making sure they “are not really costly, or really involved.” Given her work on SMART and another research study called Facebook Connect, Calfas sees a big opportunity in leveraging the social component into interventions, a component on which we now have so many new ways of assessing and intervening.
View Calfas’ talk at Models for Change ’11: Mobile & Social Technologies – Applications in Health Behavior Change
Behavior as a Measure Rather Than a Goal
[Editor’s note: the following is a summary of remarks given by Neema Moraveji, one of more than 20 presenters at October’s sustainable behavior change conference, Consumer-Centric Health: Models for Change ’11. View a video clip of Moraveji’s presentation on Health Innoventions video channel.]
Stanford University Calming Lab director, Neema Moraveji, stated that being calm enables healthy behavior and that an opportunity exists to create ‘calming’ technologies to achieve calm states of being. “Calming technologies complement persuasive technologies by removing the layers of inner distraction,” explained Moraveji, “that keep us from engaging in the behaviors we desire so much [to do].” Moraveji refered to this as an “inside out” approach in contrast to “outside in” theories and techniques that work externally to get a person from motivation and ability to habit. “Our lab focuses exclusively on creating the calm that is needed to help discover the self-efficacy that is always within us,” articulated Moraveji.
Moraveji defines calm as a state of “restful alertness,” with a focus on being productive. “But productivity, not about volume,” explained Moraveji, “[this is] about being insightful and effective…elegant productivity vs. stressful productivity.” He described the model of calming technology as combining three elements: nature and characteristics of stress; calming mechanisms; and user-centered interaction design. The focus of the work draws on the fields of psychophysiology, mindfulness, biofeedback, neuroscience, stress reduction, social cognitive theory and mind/body connection.
Moraveji highlighted a number of prototypes that he and Stanford students have developed as examples – mobile and Facebook apps, primarily, that focus on expressing gratitude, setting positive intention, sharing compassion and measuring breathing. They have been developed based on a framework of ten principles: (1) build self-awareness; (2) sustain attention: (3) create new meaning; (4) tame anger, name fears; (5) shift perspective; (6) reinforce mind-body connection; (7) support socially; (8) humanize interactions; (9) create commitments; and (10) simplify success.
View Moraveji’s talk at Models for Change ’11: Calming Technologies
Getting Past the Dissonance of Behavior Change
[Editor’s note: the following is a summary of remarks given by Vic Strecher, one of more than 20 presenters at October’s sustainable behavior change conference, Consumer-Centric Health: Models for Change ’11. View a video clip of Strecher’s presentation on Health Innoventions video channel.]
The message from University of Michigan professor and HealthMedia founder, Victor Strecher, Ph.D., M.P.H, was two-fold: tailoring at the individual level in terms of messaging and coaching can be highly effective in eliciting behavior change and utilizing technology to both create and deliver a tailored intervention can lead to very program-effective and cost-effective results. Strecher began his presentation by illustrating how individualized tailoring is more effective than general messages by highlighting a number of studies. Upshot: the greater the depth of tailoring, the greater the impact on behavior change. The challenge, however, explained Strecher “is that tailoring deeply is hard, you really have to be thinking carefully and it takes months longer to tailor something more deeply.” It is very important to tailor from the core of a person’s situation/condition – things like change barriers, motivation to change, self-efficacy – not just the outer rings of demographics and health status or disease.
Strecher also used studies to show that coaches have more impact on change than simply giving someone a pedometer and some educational material, for instance, and asking them to “just do their best.” Coaches work with an individual to set goals, and push towards stretch goals, among other tactics that move the individual closer to new behavior. But “coaches,” warned Strecher, “can be expensive, on the order of $2,000-$4,000 per year…and not readily available to all.”
The encouraging news, shared Strecher, is that it is possible to use digital health tools to “scale with quality and that’s one of the things that has been hard [in the past] to really do effectively.” Strecher states that a digital health platform needs the following capabilities in order to be effective: (1) integrated; (2) data-centric; (3) evidence-based; (4) adaptive and (5) longitudinal. It is important to incorporate multiple components because “there is no one perfect single solution for a large population,” cautioned Strecher. Data tracking and analyses can help with predicting the kinds of behaviors likely to be associated with good health. According to Strecher, “the content of behavioral interventions needs to be built on a basis of theory-informed (vs. theory-driven) research.” Tailoring tools also need to be adaptive in order to provide just the right help at the right time – “ecological momentary intervention” – based on ongoing gathering of information in the moment – “ecological momentary assessment.” Finally, more profound insights come from looking at progressions, patterns and correlations over long periods of time.
Strecher was quick to point out that these tools are only as effective as a person’s receptivity to hearing what are, often, difficult messages about need for change. He expressed his perspective that financial incentives ultimately do more harm than good in creating receptivity, and that behavioral strategies, such as Motivational Interviewing, while useful, are not always effective in breaking down the most entrenched of defenses. He stated that getting people to transcend themselves through a defined and articulated personal mission or value may be a way to counteract the dissonance or threat that people experience when faced with the prospect of behavior change.
Referring to the results of a study that tested the impact of making self-transcending values top of mind before having participants engage in health dialogues, Strecher explained, “when they write down their core values they are much more likely, compared to people who have just written down something else, like their daily routine or the events of the week, or whatever, to become less defensive and accept health messages.” “We should really be turning this paradigm around,” advocated Strecher, “and [have people] think about energy to achieve a purpose in life, a mission in life, things that relate to your core values.” Reframing in this way, Strecher stated, gets the person to see disease in a different light, as an obstacle standing in the way of achieving her personal mission.
View Strecher’s talk at Models for Change ’11: Towards Scalability & Sustainability in Behavior Change Programs
Self Quantification – Self Knowledge Through Numbers
[Editor’s note: the following is a summary of remarks given by David Reeves, one of more than 20 presenters at October’s sustainable behavior change conference, Consumer-Centric Health: Models for Change ’11. View a video clip of Reeve’s presentation on Health Innoventions video channel.]
David Reeves, Product Head for Limeade, is one of those adventurers who has taken on “personal science experiments with a sample size of one.” As a Quantified Self (QS) meet up organizer, Reeves has been privy to the variety of reported motivations that have led a growing fringe to embark on self-quantifying activities. “Some people are trying to improve things related to pain and chronic illness,” reported Reeves, “while others are just incredibly curious optimizers and really kind of motivated to figure something out and analyze it and really understand it through numbers and improve it.” One of the QS examples highlighted by Reeves was a Crohn’s disease sufferer who, after not finding any relief from prescribed medications, was able to alleviate many of his symptoms following experimentation with his genetic data, sleep patterns, exercise and eating behavior, and nutritional supplements. There is not cure for the disease.
Reeves ran down four technological factors that are enabling these efforts, as posited by QS co-founder and Wired journalist, Gary Wolf: smaller and cheaper sensors, mobile phone computers, content sharing tools, and cloud storage and computing. Reeves suggested that the relevancy of QS to more general behavior change is in “the long term potential for tools to get packaged [in consumer-friendly ways] and made easier for people to use, and the ability to get more meaning from it.” Feedback loops, he explained, are an integral part of the process to use data to create a story that resonates with the individual and ultimately, drives behavior change.
View Reeve’s talk at Models for Change ’11: Quantified Self: Self Knowledge thru Numbers
Leveraging Personal, Ego-Centric Networks
[Editor’s note: the following is a summary of remarks given by Jan English-Lueck, one of more than 20 presenters at October’s sustainable behavior change conference, Consumer-Centric Health: Models for Change ’11. View English-Lueck’s presentation on Health Innoventions video channel.]
As David Freedman pointed out and REI and Safeway demonstrate, the workplace can be a powerful platform for mediating change. According to medical anthropologist and San Jose State University Dean, Jan English-Lueck, Ph.D., the workplace as institution represents one of two different scales for behavior change. “The other scale refers to the networks that individuals create on their own, so-called ego-centric networks,” explained English-Lueck. The importance of understanding personal networks is critical because “when we get into the world of well-being, it stops being a form of knowledge that is owned by the healthcare system [such as ‘illness’] and becomes a form of knowledge that is much, much broader.” English-Lueck stated that various influencers within a host of networks – families, friends, affinity groups, etc. – help individuals understand and interpret information, and act on it, or not.
The ease with which networks can be developed and extended though technology today means that the potential for mixing and matching different “logics and practices” grows greater all the time, and consequently the job of determining the nodes of influence more complex. Nevertheless, the effort to figure things out is worthwhile because, as English-Leuck expressed, “every network that an individual participates in can be mobilized to support health.”
One of the growing trends that English-Lueck highlighted is the self-quantification movement where individuals are conducting experiments on themselves to maximize well being. “There are people,” explained English-Lueck, “who are thinking about and engaging in some really experimental ways to think about how you do something new, how to measure what you are doing so you know what it is and how you aggregate that data so it can actually become actionable.”
View Dr. English-Lueck’s presentation at Models for Change ’11: Small Experiments: Tinkering with Well Being
The Consumer-Centric Health: Models for Change conference featured more than 20 presentations on all facets of health behavior change. The presenters represented diverse fields of medicine, employer health, mobile technology, health insurance, gaming, public health, research, and anthropology. The 1½ day conference, held at Seattle University in Seattle, Washington, began with an opening keynote on Oct 12, with the main sessions on Oct 13, divided into three sections (1) what’s working in behavior change; (2) how to scale behavior change; and (3) what else is needed to make behavior change more effective and sustainable.
A written summary of the conference presentations is available for download.
Common themes that surfaced were:
(1) Consumer and patient activation: while the term was referred to in quite different contexts, it was unanimous that becoming activated, from acquiring a basic knowledge of the cost of care to actually taking on accountable self-care roles, resulted in more favorable health choices and outcomes. Speakers noted numerous activation triggers, everything from benefit plan design, financial incentives and cultures of health to coaching and self-tracking to social networking and gamification.
(2) Self-awareness raising: many speakers talked about the need for people to more objectively view their health conditions and goals as a precursor to behavior change. Motivational Interviewing, cognitive behavioral and mindfulness techniques were most often mentioned as awareness raising tools used to lay the foundation for essential motivation, self-efficacy and capability components of change.
(3) Social context: an individual’s social environment was portrayed as both an inhibitor and accelerator of change, especially through increasingly technology-enabled social networking. However, low-tech approaches that mobilize families, co-workers, informal caregivers and lay helpers can also be very influential.
(4) Personalized interventions: the value of tailoring interventions based on individual characteristics was a consistent thread, as was the need to customize beyond just “outer ring” demographic and health status attributes. The notion of “deep” tailoring based on a person’s core values was raised several times as an important future direction for sustained behavior change.
(5) Mobile technology: emerging technologies, especially mobile phones and applications, were noted as cost-effective enablers for spurring activation, raising awareness, leveraging the social context and providing a platform for personalization and self-support. The ability of mobile to enable continuous and adaptive interventions that leverage compressed feedback cycles and lower-touch professional supervision was also noted.
(6) Positive states of being: there was general agreement that the challenge of behavior change is more likely to be met when an individual is experiencing positive emotional states. A number of presenters referred to the importance of helping patients and clients to reach states of calm or flourishing because under these conditions healthy behavior becomes a natural by product. Some speakers saw opportunities for technology to help enable and encourage these states, from Facebook applications to mobile apps to social games.
Videos and slides for each presentation are available on 2011 Videos & Slides page.
I’m Jane Brock, Chief Medical Officer for the Colorado Foundation for Medical Care, the Medicare Quality Improvement Organization (QIO) for Colorado. I work primarily with the Integrating Care for Populations and Communities National Coordinating Center team to help QIOs across the country improve care transitions and reduce unnecessary hospital readmissions at the community level. I will be talking about the intersections of government policy and behavior change interventions during the “Tracking Opportunities and Enablers for Scaling Programs and Sustaining Change” session. We recently completed a 14-state QIO initiative, funded by the Centers for Medicare & Medicaid Services (CMS), to improve the quality of care transitions between care settings and reduce preventable hospital readmissions through patient engagement and activation. One of the primary lessons we learned from that project was the importance of local community ownership to create and sustain collective action and impact. We are now part of the team assisting CMS in diffusing these principles through the Community Based Care Transitions program, which supports collective community action using a new Medicare payment mechanism.
(editors note. This “and now a word of introduction from…” comes from Dr. Jane Brock, one of 20 conference presenters. From time to time we’ll post an intro as a way for Models for Change conference attendees and other interested parties to learn a bit more about a speaker beyond the title and bio)
I’m David Reeves, Director of Product Management at Limeade, a provider of social wellness services to high performance companies and health systems. In addition, I co-organize the Seattle chapter of the Quantified Self meetup groups, which occur in dozens of cities every month. In my talk, I’ll be touching on each of these roles. I’ll discuss the role of self-tracking and quantification in behavior change, along both ends of the motivation spectrum. In addition, I plan to discuss our efforts at Limeade to help individuals and companies improve their well-being by making these techniques accessible, social and fun.
(editors note. This “and now a word of introduction from…” comes from David Reeves, one of 20 conference presenters. From time to time we’ll post an intro as a way for Models for Change conference attendees and other interested parties to learn a bit more about a speaker beyond the title and bio)
I’m Rod Hart, populationist & health interventionist. I manage Health Promotion and Wellness at ODS Health, and live just southwest of Portland in the stunning Willamette valley. My work and that of my team focuses on applying behavioral-based models of change to individuals, groups and communities of care. Some of this work will be featured in the NCQA Leadership Series this fall as a case study profiling the ODS Health Coaching program. It is entitled Integrating the Patient Activation Measure Into Health Coaching to Improve Patient Engagement. The Leadership Series profiles the efforts of leading health plans to improve outcomes and engage patients in their own care. I just completed Cycle Oregon (Going Coastal), a 499 mile –seven day ride, the Cycle Oregon Fund distributes funds to towns, organizations and bicycle-related causes in Oregon.
(editors note. This “and now a word of introduction from…” comes from Rodney Hart, one of 20 conference presenters. From time to time we’ll post an intro as a way for Models for Change conference attendees and other interested parties to learn a bit more about a speaker beyond the title and bio)