CONNECTED HEALTH CONFERENCE • SAVE THE DATE • October 16-18, 2019 • Boston, MA
Dr. Kate Wolin, Co-Founder, Coeus Health
We increasingly hear calls from digital health investors and thought leaders to pay more attention to whether solutions work. These align with my experiences as to why digital health companies are seeking to bring behavioral science into their product strategy and roadmap. Silicon Valley has begun to embrace health psychology and its behavior change expertise, but far too often their solutions aren’t yielding the sustained behavior changes necessary to drive meaningful health outcome change.
At the 2019 Connected Health Conference, we’ll talk about a few of the reasons behavior change is hard and what you can do about it. We know that simple behavior change formulas aren’t sufficient and one of the reasons is that they fail to the inherent complexities.
For decades, one of the cornerstones of population health has been that context matters. It is built into the most well supported and commonly used behavior change models (e.g., social ecological model, self-determination theory, social cognitive theory) and is central to the current focus on social determinants of health.
Silicon Valley has focused digital health on “hooks” and “habits.” In psychology, habits are subconscious or unconscious actions or reactions to cues. Behaviors are conscious (or intentional) reactions to cues. What the current habit and hook mindset misses are the conscious things that people think about, what we might colloquially call the consequences. Cues are commonly social or environmental. Habit change requires the individual to have the capacity to change their cues and environment. For example, in promoting physical activity habits, an individual might be instructed to leave sneakers by the front door as a cue to be active. Habit interventions too often ignore the consequences of the cue - what that individual should do when they open the door to an unsafe physical environment. The cue in this case is followed by a negative reinforcement or punishment, which leads us to NOT do the behavior. Behavior change interventions for that same individual recognizes that they live in an area where walking isn’t safe and teach the problem solving skills that will help them navigate a structural environment they may not be able to change.
Intent and opportunity combine into what scientists often call the context for behavior change. The social context includes social norms and cultural beliefs, and also includes social support. All are consistently associated with behavior change. Using physical activity as an example behavior, studies show that changing social norms increases in physical activity. Scientific reviews also find that social support is associated with physical activity in everyone from children to older adults. This support could be both the encouragement of others and having someone to be active with, highlighting that even social support is a multidimensional construct and should not be oversimplified when seeking to embed it within an app or platform. It is also important to know that creation of social connection is not the same as creating social support. Sharing behavior change progress with others can lead to “nagging” from friends and family, which is counterproductive. Leaderboards and streaks can be discouraging to some and encouraging for others. All “support" isn’t good - this is why changing behavior is hard and not formulaic. [Reminder, these relationships exist across health behaviors, not just physical activity, which is used here for illustrative purposes.] Digital health programs and platforms that want to create true habits (particularly those that are sustained long enough to deliver changes in health outcomes), need to support individuals in changing their social context in order to create the unconscious processes foundational to real habit change.
Changing or differently navigating the environmental context is also important, and often times, more challenging, and is sadly missed in many digital health apps. The importance of the physical environment is obvious to anyone who has ever struggled to find the stairs in a new building, driven through a neighborhood classified as a “food desert,” or tried to take a walk in a neighborhood with missing (or broken) sidewalks. The physical structures around us can facilitate (or inhibit) our health behaviors. Behavior change models and research literature have been studying this for decades, but changing contexts is difficult for individuals, often occurring at the community or societal level. Yet, we should not ignore that these contexts matter or believe that addressing them in the context of health behavior change requires societal level changes. Studies have evaluated approaches to help individuals navigate challenging environmental contexts, with success. Doing so could mean changing the context, but also changing the individual’s sense of agency. For example, creation of walking groups helps individuals both mitigate some aspects of feeling unsafe in the neighborhood and creates social connectivity.
The intersection of context and agency highlights another important and complex feature of behavior change models - at their core is the intersection of different components. Context and motivation do not exist in isolation, but interact, which means they can amplify or inhibit each other. The best behavior change programs are thus developed with behavior change strategies as part of the integrated whole and not as a feature in a roadmap.
It is important to applaud that behavior change science is now part of the conversation at many digital health startups (and giant companies tackling health challenges like Apple and CVS). But relying on overly simplistic models of habit change, like those put forward in lay press books and day long training sessions ignores that human behavior is inherently multilevel (and thus, complicated). Individuals operate within social and environmental contexts that can inhibit behavior change and habit creation. To best improve health, digital health solutions must move beyond prescribing behaviors and providing reminders to true multidimensional models and processes.
Dr. Kate Wolin is a serial entrepreneur and behavioral epidemiologist. She is a Co-Founder of Coeus Health, which aims to speed the translation of research tested health and wellness programs to the real world.
Why is Behavior Change so Hard? Successes and Failures from the Field
In this CHC19 session, Dr. Kate Wolin joins a panel of leaders in the field of behavioral medicine who will share failures and successes in designing, adapting, and implementing behavior change programs.