Whether it’s your late-night chocolate indulgence, smoking an occasional cigarette, or consistently putting off losing those last five pounds, we all have bad habits that impact our health. Mad*Pow is an experience design agency thinking about ways that technology can help us improve our habits through a concept called behavior change. Mad*Pow works with clients to develop apps and digital tools to help patients make changes in their everyday lives to improve health or manage chronic conditions.
I recently spoke with Dustin DiTommaso, VP of User Experience at Mad*Pow, about the idea of behavior change. During our discussion, I learned more about how technology can help humans kick those bad habits, and DiTommaso told me about some ways that the agency has incorporated the concept of behavior change into recent projects.
First, can you explain some basic concepts in behavior change, and how they relate to the medical field?
The focus of the work that my team and I do is on creating products and services using digital technology to facilitate behavior change in different health domains. This includes areas such as nutrition, weight loss, sleep, mood, physical activity, managing chronic conditions like diabetes and hypertension and even psychological issues like dealing with depression or anxiety.
Essentially, we take what is normally done one-on-one with a clinician and a patient, and create tools and games to support the desired behavior-change outcome. The idea is to help the patient self-regulate his or her actions to transition from unwanted to wanted behaviors. These digital tools can then be used in addition to the one-on-one relationship, or can completely replace them. We’re looking to design interventions that provide enough autonomy, structure, feedback and guidance to help people change their behaviors so they can ultimately improve their health status or manage an existing condition.
It seems that what motivates behavior is so unique to an individual. So how do you engineer or design a specific change?
Of course as individuals, we all possess different motives, barriers, beliefs and attitudes but we also have universal needs that we can design for when we’re engineering change. We know that in order for a person to enact any behavior in any given moment they need to have sufficient capability, motivation, and the opportunity as afforded by their current environment. We target each of these three components to affect behavior. For example, we can make something easier or harder to accomplish in order to affect capability. We can take a big goal and make it easier to achieve by breaking it down to small achievable actions. To create opportunity, we design tools and services that fit in a person’s day-to-day routines or critical moments and present them with just in time nudges or calls to action. And then there’s motivation. No matter how easy you make something or how opportune the moment is, if you don’t have the motivation to enact that behavior, it’s not going to happen. As there can be no change without action, there is simply no action without motivation.
So, designing for change is very much about understanding and facilitating human motivation. We draw from different forms of motivational psychology but especially
Self-Determination Theory, which considers the multiple motives people have for enacting or failing to enact intended behaviors. We can use the core psychological needs SDT states that we all possess – competence – or the need for growth or mastery over the environment and within ourselves, autonomy – feeling like we are the agent in control of our actions, and relatedness – which is the need to meaningfully interact and connect with others to guide the direction of the behavior change products we design.
What’s an example of a digital ‘tool’ that helps with behavior change?
One recent example is a project that we did with the Joslin Diabetes Center, which has a very successful in-clinic behavioral weight loss program. Patients are typically able to lose 7-10% of their body weight during the 12-week program through a combination of nutrition, education, physical activity, monitoring and support. While the program is successful for people in-person, Joslin wanted to make the program available to people who can’t make it to the center.
We wanted to preserve the essence of the 12-week program and create a digital platform that could accomplish similar outcomes. We retained the diabetes education and skills training, scaffolded exercise and nutrition plans and added tools like glucose, mood, diet and exercise tracking, data visualization and informational feedback and guidance. We also created communities and social mechanics so participants could retain the experience of peer support and influence that was so powerful in the in-clinic program. The digital version is currently in a clinical pilot and we’re looking forward to learning how participation, engagement and outcomes compare.
Another project we’ve designed is a mobile behavior change game called Hotseat, which is intended to help combat sitting disease through active social gameplay that gets you up and out of your seat. The game works by having a bank of 2-minute activities players can agree to perform. The app scrapes the user’s calendar to find the most opportune moments to take these breaks and cues the user throughout the day to perform them. Hotseat also includes a simple game mechanic, where users can earn the right “pass the Hotseat” to coworkers, friends and family, creating cooperative and competitive gameplay to keep engagement high.
Looking at the outcome of these tools, how do you measure or quantify results?
A big part of that is deciding at the beginning of a project which metrics we’re looking to move, and what a meaningful percent of change is. The metrics can be behavioral – I’m doing something more or less frequently, biometric – like reducing BMI or glucose levels, cognitive – demonstrated domain knowledge or psychological markers like mood, self-confidence or stress.
When the desired end markers are identified, we take a baseline before the intervention to see how outcomes are affected as participants interact with the product over time. Ideally, we can adjust the scope, intensity and focus of the program over time as we get data.
For example, the Hotseat app – how was that tested?
We did a three-month pilot study with the American Heart Association to test whether Hotseat was helping people be more active. For this product, our goal was to get people closer to the national activity standard of 30 minutes per day by increasing the number of activity breaks a person takes in a day. For Hotseat, since it’s not a clinical app, all activity is self-reported through the phone. The app has a 2-minute timer that you can’t disengage until it has counted down, and there is really no incentive for not doing the activity or false reporting.
We had nearly 78% engagement throughout the pilot, and 67% of the pilot group increased their daily activity minutes playing Hotseat.
One thing we didn’t expect – and I would love to do more research on this – is that by engaging with Hotseat and playing the game with other people, it created the motivation to actually do more than what we were asking for. When we did follow-up interviews, users said things like, “when I got a reminder, I would grab friends and take a longer walk at lunch.” So we were building up the behavior and interest, creating a gateway effect to sustained health activities.
The idea of changing someone’s fundamental behavior rather than forcing them to do something seems to have been ignored by the medical community for quite a while. Why do you think it has been ignored for so long, and how is the perception of the field changing?
The field has always been interested in changing people’s behaviors, but exactly as you put it, it’s been more focused on ‘making people compliant’. We can trace this back to the behaviorism popular during the 1950s through 1970s. The radical behaviorists of that time saw external variables as the principal causes of behavior and attempted to control behavior through reinforcements and punishments. While operant conditioning can lead to short-term behavior change, it comes at a cost to perceived well-being and isn’t effective for sustained long-term change. Thankfully, we’ve had decades of empirical research that shows more holistic, humanistic and non-controlling approaches to behavior change is not only more effective for producing long-term change but can lead to increased well-being, improved self-regulation, happiness and eudaimonic living. This is where my interests lie. When we can use design and technology to help people flourish and thrive in areas they want to, we’ve created true service value for everyone involved.
Shannon is an Associate Consultant at DRG Consulting, where she helps clients in the life sciences approach strategic problems. As a new-comer to Boston, she's very excited about all of the medical innovation happening in her neighborhood, and loves learning about the people and resources that make it so vibrant. Shannon also holds a PhD in Biomedical Engineering where she studied the biomechanics of bone regeneration. She can be reached at firstname.lastname@example.org.
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