I attended the Mobile Health conference in sunny Palo Alto last week (May 16-17). It wasn’t a typical run-of-the-mill academic conference with suits and stiffness – we sat at round tables, the hall was decorated with balloons, and at one point we played a little game by throwing beach balls around. I felt that the relaxed and playful atmosphere really encouraged people to approach each other more freely. In addition, food was mostly healthy, even though there were a bit too many muffins, cookies and brownies around for mindless grabbing.
The focus this year was “baby steps” in three areas: behavior change, collaborations, and product development. BJ Fogg started the program by emphasizing the importance of starting small.
- Failure’s interesting only after you have something small that works. Start simple, test as soon as possible, learn from your mistakes.
- Which one would yield more insights and a better product: one 100-hour trial, or 25 trials of 4 hours each?
As an example, his slides about Top 10 Mistakes in Behavior Change didn’t take much time to do but they’ve reached a large audience and received a lot of attention. Simple and easy to understand, doesn’t require much effort.
I’ll attempt to cover the key themes from the conference in the rest of this post.
Eric Hekler continued on the same line as BJ Fogg and tackled the problem of effective intervention development. He talked about the typical lifecycle of a research project, which is so slow that it can take 7 years or even more from the conception of the study to the publication of the results. Not to mention that the general public may not ever hear about the results, because they don’t read academic journals. Meanwhile, society and technology have moved on to perhaps unexpected directions.
We really need to get into the mindset of doing things as quickly as possible. Basically, we get ideas from three sources:
- Theory. Now, theory doesn’t need to be complicated. It can be just your own assumption of how something works.
- Users. That is, the real world. Observing, understanding, empathizing.
- Previous work. The mountains of literature.
We usually spend too much time on crawling through the previous work and too little time on looking around in the real world and trying to understand what people actually are doing and why. It would be better to just run crummy trials to test assumptions at first, and also trying to do those crummy trials without needing to code. After all, in the beginning we’re only testing the psychological experience/recipe to see if there’s any point to go further.
There’s obviously the challenge of finding rapid funding channels. Sometimes testing assumptions might mean doing it for free (or, at universities, doing it with students who do it for credits). But if you love what you’re doing and think it’s going to change the world for the better, wouldn’t it be worth it?
Anyways, in case it’s not clear yet, the concept of agile science sounds really good to me. In hopes of sharing resources and ideas between researchers and developers, Open mHealth initiative aims to create an open mHealth architecture and open community.
Related to agile science, the recurring message in many speeches was that we must not fear failure. Failing fast will quickly give us an idea of what didn’t work so that we can improve. Moreover, if we build something small and test it quickly, we haven’t wasted a lot of resources, time and money in developing something that ultimately wouldn’t work anyway. Very few companies do exactly the same thing that they started doing – more often than not, they have had to change the course and re-think the original idea several times.
Research groups and companies should also embrace the mindset of failing fast so that there is the freedom to fail, honest feedback is given, and it’s okay to ask for help.
Someone in the audience raised a question that perhaps we shouldn’t fail fast when giving out health-related advice. Even if we’re giving right advice to 75% of people, what if 25% of people get the wrong advice? David Sobel, the wise man who the question was directed at, responded that we’re pretty dumb. The thing with science is that evidence keeps accumulating and changing, and we have to deal with what the current hypothesis is. And we can definitely say that some things are better than others, and with food it’s also about quantity.
Changing the World
Alexandra Drane from Eliza Corporation wants us to make health sexy. After all, that’s how the opponents (food, beverage, and tobacco industries) are trying to seduce us into succumbing to their temptations. And they are also spending enormous amounts of money per individual to achieve their goal, whereas spending into health promotion is miniscule in comparison. Brochures about weight loss and pictures about damaged kidneys are a lot less appealing and interesting to consumers than advertisements with scantily clad women who caress soda bottles. Perhaps we should be more outrageous, direct and unexpected when delivering health messages.
In addition, we have to mention the unmentionables: real concerns that people have in their lives and that drain their energy, making them want to turn to stuff that gives them short-term pleasure. Concerns such as relationship problems, trying to make ends meet, stress at work, or bad sex life. The vulnerability index combined from such factors has much higher predictive power on life expectancy and quality of life than disease index. Thus, people need to be treated compassionately and humanely. Most of us want to be healthy, but it’s difficult to figure out how. We should aim to help people do what they already want to do.
On another note, Nikhil Arora’s mushroom kits made me want to start my own home mushroom farm, and I wasn’t the only one. He told the inspirational story about his company Back to the Roots. In short, they got the idea of growing mushrooms in an urban home, starting with testbeds in buckets in dorm rooms and getting the first successful crops. They then moved on to iterating the idea and presenting it first to the ideal audience (farmers’ markets). Now they have a product which is innovative, useful and promotes sustainable lifestyle. He said that the most positive response has come from kids who are astonished by being able to grow their own food in 10 days.
So, you can have a business that does good for this world. It makes me happy.
One issue with dissemination of research is that too often we wake up to think about it when the project is about to end. Sheana Bull from University of Colorado Denver stressed the importance of designing for dissemination from the very beginning. This involves identifying and engaging the target audience and the people who have the ability to reach the target audience (schools, workplaces, organizations, healthcare). Community-based participatory research would be a good approach to take. Also, concepting and piloting can benefit a lot from online tools: focus groups can be conducted online, and various surveys are easily administered online.
One example of collaborative research is the project HealtheSteps which aims to increase physical activity among all patients in the area. They are screened through healthcare and the intervention is personalized to each individual through mapping the small changes that they can start making in their own lives.
A couple of speakers pointed out that personal feelings always play an important role in collaborations as well. Everyone wants something out of the relationship and wants to be treated fairly – people should be honest about their intentions.
Two alternate ways to think about ROI:
- Research of Interest
- Results of Importance
Besides collaboration in research and development, facilitating patient/citizen collaboration is also cool. PatientsLikeMe and CureTogether are nice services, but perhaps their sort-of weakness is that they are meant for everyone. Global networks such as Crohnology (currently in beta) that are focused on a certain condition or disease might be more inviting and empowering, since people’s experiences and needs are similar.
In behavior change, belief in own abilities and in the benefits of the change are a must. While explaining his Behavior Model that consists of motivation and ability dimensions, BJ Fogg stated that ability is the most important thing. Motivation can fluctuate and it often wears off over time, but if we make the behavior very easy to do, it can be done even with relatively low motivation.
Group support is powerful not only because of the boost you get from the group (and the accountability), but also because people in the group share their experiences and concrete how-to examples of succeeding in behavior change and overcoming barriers.
Besides, nobody likes the word willpower. Willpower and motivation may be enough if the spark that initiates behavior change attempt is the result of a huge event or epiphany (such as loved one dying). But we can’t rely on people having epiphanies. We need to provide them tools and how-to tips to make the change easier and effortless; break big goals into small steps. And we need to care about them, not just because of healthcare costs, but because everyone has a right to be treated as a fellow human being with feelings and dreams.
David Sobel from Kaiser Permanente (in preventive medicine: has been trying to prevent medicine for more than 30 years) held a powerful presentation about empowering people. In chronic disease management, the best way to help people has been to let them help other people so that they can find solutions together and gain confidence. He also told a story about a diabetic patient for whom nothing seemed to work, until one day he asked the patient: “What do you really enjoy doing?” At that moment, the patient smiled and answered “trout fishing”. For a while, they could both be somewhere else than in the world of ailment – they could stand in the stream and feel the breeze of a soft wind on their face. At that moment, the doctor stopped seeing his patient as a diabetic and started looking at him as a trout-fisher. And that was also the moment after which they started having progress in lifestyle changes.
So, three steps to personalization:
- Find people’s passion: what do you really enjoy?
- Discover their solutions: what would work for you?
- Celebrate their success!
Services should be designed to minimize the stress they cause to users, says Neema Morajevi from the Stanford Calming Technology Lab. Makes sense. They’ve created a draft of Design Cards intended to help designers choose strategies to make the user experience stress-free. It’s good to be reminded about this side of things, but we’ll see how applicable those cards are in practice.
In the spirit of small trials, they did a little SMS study during the conference. Basically, we first practised deep breathing and then got text messages during the rest of the day day asking us to take a few deep breaths or express gratitude to someone. We replied to the message by telling how many breaths we took, how many people we thanked, or how these actions made us feel. It’s a pretty good way to deliver small interventions, as long as the number of messages doesn’t grow too high.
Some other stuff that stuck with me:
- Not only can you now use your smartphone to measure heart rate and stress, you can also use it to analyse urine samples. Lab in your pocket!
- Hemi Feingarten, Fooducate, about processed food: “The longer the shelf-life of the product, the shorter the shelf-life of humans.” I totally agree. Also: junk food has 90% profit margin, whereas it is 10% for vegetables. If you were a greedy food industry person, which one would you want to sell?
- One person or a handful of people can nowadays use technology and social media to create large changes. Examples: Egyptian revolution, pink slime petition.
Good conference. One of my small steps was the decision to stand up during the second day – sitting kills.
The presentations and slides should be on the conference website soon, so check them out when you have a chance!