Nudging health behaviours through smartphones
26 May 2014
Millions of people die in both the developed and developing worlds from preventable diseases such as cardiovascular disease and diabetes. By adopting healthier lifestyles and making the best use of the latest evidence-based healthcare, people can reduce their risk of premature morbidity and mortality. Governments and healthcare providers need more effective strategies to encourage healthier choices and increasing interest is being directed at the potential role of new mobile communication technologies as a mode of intervention delivery to help people improve their health.
Whilst most of us like to believe that we possess good judgment and are effective decision makers, the truth is that we are often not when it comes to decisions about our health. Despite being fully aware of the risks, people continue to smoke and drink alcohol to excess, fail to take medications as prescribed and forget to attend their clinic appointments. Time and time again we see people making poor health related decisions that are harmful and out of keeping with their underlying intentions.
Attempts to change many health-related behaviours have been relatively unsuccessful to date. In this article we suggest that we should be more optimistic going forward as a consequence of two underlying trends. Firstly, new insights from across the behavioural sciences – but particularly behavioural economics -have the potential to promote sustainable behaviour change at little or no extra cost. Secondly, the near ubiquitous access to mobile computing technologies such as smartphones and tablet devices provides an effective platform for monitoring health behaviours and delivering behaviour change interventions.
Influencing behaviour change
The field of behavioural economics draws on findings from both psychology and economics. Recent work in the area has challenged traditional assumptions of rationality in human judgement and decision-making that have dominated the majority of frameworks used to understand behaviour and design behaviour change interventions1.
Evidence from behavioural economics demonstrates that behaviour is strongly influenced by environmental or contextual factors and is subject to social influences, cognitive biases and the format in which choices are presented. In this regard, behaviours can be strongly influenced by deliberately altering the ‘choice architecture’, as Thaler and Sunstein call it in their influential book Nudge: Improving Decisions about Health, Wealth, and Happiness2.
The publication of ‘Nudge’ caused an explosion of interest around behavioural economics. Policies that change the context or ‘nudge’ people in particular directions have captured the imagination of policymakers at a time when the limitations of traditional approaches to changing behaviour have become apparent. The government of the United Kingdom has established a Behavioural Insights Team (BIT) who has implemented nudge type policies across government departments including in the healthcare domain.
The initial operating framework for the work of the Behavioural Insights Team (BIT) was through the Mindspace framework3. Mindspace presents a summary categorisation of a body of (largely contextual) effects on behaviour that have been observed in both experimental and real world settings, captured in a simple mnemonic. All of the Mindspace effects (see Table 1) (messenger, incentives, norms, defaults, salience, priming, affect, commitment and ego) have a good evidence base supporting their effectiveness and can be used to explore not only the reasons behind irrational or sub-optimal decisions but also how behavioural insights can be used to deliver more effective behaviour change. Such interventions can be deployed across different communication platforms including increasingly mobile devices such as smartphones and tablet devices.
Table 1: Mindspace effects
Mobile communication technologies
The way in which people communicate with each other has changed remarkably over the last decade. Clunky desktop computers have been replaced by portable laptops and fixed landline telephones have given way to mobile phones. Mobile communication devices are widely used around the world with the number of subscriptions for mobile phones outstripping the population in many developed countries.
Of all the different information and communication technologies available, mobile communication networks and mobile phones have reached the largest number of people with their adoption said to be growing faster than any other consumer technology in history4.
As a consequence of their popularity and portability, mobile phones and associated devices are being increasingly considered as a platform for delivering interventions that promote health and prevent disease. Mobile health (mHealth) is the term used to describe the use of mobile communication technologies to deliver healthcare and is a rapidly expanding sector. mHealth is made possible through the variety of technical functions supported by these rapidly evolving mobile technologies, which include voice calling, short messaging services (SMS), video-conferencing, GPS services and Internet connectivity.
A large number of mHealth interventions have been introduced to improve health outcomes, ranging from relatively simple SMS appointment and medication reminders, to more complex interventions incorporating body sensor networks5. There is good evidence to support the role of mHealth platforms in opening up new opportunities and channels to influence health behaviours. SMS text messages are now widely used in health promotion campaigns, with positive behaviour change identified in a number of evaluated intervention programmes6.
Mobile phones have a particular attraction as a platform to encourage behaviour change given their wide adoption, portability and technical capabilities. They can be used to deliver motivational messages, support and information to the recipient. They can also be used to record information related to diet or physical activity in real time. Improvements in interface design, batteries, processors and wireless technologies are enhancing the power, personalisation and mobility of handsets. We are now seeing smartphones as the hub of body sensor networks that see wearable sensors on the body measuring health related parameters (eg blood pressure, blood glucose). Rapid developments in the field are improving the potential to deliver increasingly sophisticated behaviour change interventions.
Behaviour change through mHealth
Through their ubiquity and accessibility, smartphone technologies provide an effective platform for the delivery of behaviour change interventions at the population level. Their small size, portability and enhanced functionality mean that behaviour change interventions can be administered at any time and place. Behaviour change interventions delivered through smartphones may take the form of simple SMS text messages or more complex app-based solutions that are capable of better harnessing the powerful technologies housed within latest generation smartphones.
Insights from behavioural economics can be incorporated in the design of interventions to increase their effectiveness. SMS interventions can be phrased to increase their salience or highlight relevant norms amongst the intended recipients. App-based interventions can be designed to draw on information provided by the various embedded sensors within smartphones that allow users to track their own health behaviours, and personalised interventions can be delivered based on this data. The in-built accelerometer for example can track motion. An app could be specifically designed to interpret data from the accelerometer and provide users with feedback on their activity levels throughout the course of a day. This same app could be programmed to provide users with data regarding the performance of peers thus encouraging increased activity through competition. Furthermore, if the accelerometer indicates that an individual has been inactive for a prolonged period of time an intelligently timed and salient push notification could be sent through the app encouraging the user to move. This example highlights how insights from behavioural economics can be purposefully designed into smartphone apps in order to achieve desired behaviour changes.
At Imperial College London we are working on a range of behaviour change interventions that make use of mobile devices. We have recently completed a trial looking at how obese children can be supported in losing weight by committing to certain behaviours over their mobile phones. We have also investigated how different SMS text messages inspired by Mindspace can be used to reduce non-attendance at many of our clinics. The results of these studies will be published soon, alongside dozens of other projects happening across the world.
Although we should be optimistic about the potential of mHealth, the use of mobile phones as a platform for achieving behaviour change is not without its challenges. Access to handsets, good reception, and cost appropriate interfaces are all important considerations in implementing public health interventions through this medium. Although the evidence base for app-based behaviour change interventions is currently limited, this is growing and its potential is well recognised. A quick search on app stores will yield a multitude of relevant apps delivering behaviour change interventions targeted at lifestyle (eg exercise, sleep, diet, weight, smoking cessation, alcohol cessation, and mental health) and chronic disease management (eg obesity, asthma, diabetes). Robust clinical trials of app-based interventions in these contexts are needed to prove their efficacies, appease critics, and address the current lack of evidence base.
1. Kahneman, D., Thinking, fast and slow. 1st pbk. ed. 2013, New York: Farrar, Straus and Giroux. 499 p.
2. Thaler, R.H. and C.R. Sunstein, Nudge : improving decisions about health, wealth, and happiness. 2008, New Haven: Yale University Press., 293 p.
3. Dolan, P.H., M.; Halpern, D.; King, D.; Vlaev, I., MINDSPACE Influencing behaviour through public policy. 2010.
4. Boulos, M.N. and S.P. Yang, Exergames for health and fitness: the roles of GPS and geosocial apps. Int J Health Geogr, 2013. 12: p. 18.
5. Klasnja, P. and W. Pratt, Healthcare in the pocket: mapping the space of mobile-phone health interventions. J Biomed Inform, 2012. 45(1): p. 184-98.
6. Cole-Lewis, H. and T. Kershaw, Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev, 2010. 32(1): p. 56-69.
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