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Why digital behaviour change interventions will transform public health

I Introduction
II It is more cost effective to promote healthy lifestyles than treat diseases
III Digital Interventions
IV Hybrid campaigns that encourage and support change
V Resources
VI References

–submitted by Brian Cugelman, PhD

I Introduction

Imagine the next generation of health campaigns, where health departments encourage citizens to improve their wellbeing through lifestyle changes, but then go one step further, offering every citizen personal support to help them develop new lifestyle habits. Moreover, imagine offering each citizen access to the best programs, based on the latest scientific knowledge, delivered by the world’s leading experts.

In this ideal health promotion system, every smoker could work with the leading smoking cessation counsellor and develop a quit plan tailored to their particular needs and preferences, situation and social context. Now take this vision even further, and imagine the same principle applied to all lifestyle habits that affect public health, such as physical activity, healthy eating, stress management, substance abuse and self-care of chronic conditions.

This vision may sound very idealistic and extremely unrealistic, as no healthcare system can provide each citizen with inter-personal support at the mass-population level. However, there is a second best option—interactive digital technologies that can provide mass-interpersonal behaviour change support, in a way that can transform public health promotion.

This article will discuss the shift towards preventative medicine, the efficacy and limits of traditional health promotion campaigns, the efficacy and limits of digital interventions, and then look at the future of hybrid campaigns that both promote and foster change.

II It is more cost effective to promote healthy lifestyles than treat diseases

Over the last several years, there has been a shift towards preventative medicine, where governments are opting to spend money promoting public health in order to reduce healthcare costs treating preventable conditions. For instance, in the UK, the Department of Health estimated that the Government was spending £187 billion per year (over $300 billion Canadian) treating preventable ill health that could be better spent marketing healthy lifestyles. [1]

The efficacy of traditional health promotion campaigns

When designing public health campaigns, it is common to employ a range of theories, processes and tools. Commonly, they will draw inspiration from the transtheoretical model, social cognitive theory, diffusion theory, the theory of planned behaviour and others. Social marketing is perhaps the most popular framework for designing health behaviour change campaigns through the use of commercial marketing approaches, employing the 4P of marketing: product, price, place and promotion.

Health campaigns based on social marketing encourage target populations to change their behaviour in order to obtain benefits (incentives) and avoid a cost (disincentives). For instance, campaigns may encourage doctors to wash their hands to reduce the spread of infections in hospitals; they may encourage parents to give their child 60 minutes of physical activity per day for many health benefits; they may encourage older persons to get annual flu shots to reduce illness; or they may encourage teens to avoid binge drinking by framing drunkenness as uncool.

Some social marketing campaigns provide both health promotion and support, to help people achieve behavioural goals. In other words, they focus on raising awareness of issues such as screening for breast cancer risks, creating a sense of urgency, and then offering support such as a telephone hotline where women can get more information or referrals to screening facilities, ideally leading to earlier detection and greater survival rates.

Research shows that the average social marketing campaigns can influence about 5% of a population’s behaviour. (Average correlation effect size across interventions, r=.050). For instance, if 60% of a population was performing a health behaviour before a campaign, 65% would be performing it after. [2] This 5% impact is a ballpark figure that varies from population to population, and from behaviour to behaviour. Although 5% may seem small, at the population level, small shifts in public behaviour can translate into large health impacts.

The limits of health promotion

Many health campaigns encourage people to change their behaviour in order to achieve benefits. Awareness and habitual changes can be easier to address with social marketing. However, many health behaviour changes are difficult to support with social marketing.

Campaigns focused on habitual change may remind doctors to wash their hands, remind children to look both ways before crossing the road, or remind people to book annual appointments with a specialist for a range of health issues. Some of the more difficult changes include dealing with substance abuse and addictions, changing social norms that reinforce unhealthy lifestyles such as binge drinking, and managing mental health.

It is one thing to fire-up a person’s desire to achieve personal goals; it is quite another to join that person on the long and difficult path towards reaching those goals. Social marketing campaigns are good at raising awareness and potentially at raising motivation, but limited in their capacity to service that awareness and motivation.

Many campaigns encourage people to get physically fit, but why can’t more fitness campaigns offer interactive services to help citizens identify fitness options tailored to their particular lifestyle, location, time constraints, tastes and desires. Many campaigns encourage people to eat healthier and provide helpful guidelines, but why can’t more nutrition campaigns provide individuals with personal support, to help them design a balanced diet tailored to their lifestyle, preferences, tastes, priorities and family needs?

III Digital Interventions

Digital interventions can facilitate individual change, potentially helping millions

Research shows that digital interventions can motivate people to live healthier lives. So it is surprising that more public health campaigns do not provide interactive support services. Examples of digital interventions include websites and mobile applications that help people achieve health goals such as exercising more, quitting smoking, taking medication or managing anxiety disorders. These systems mimic the relationship between a patient and their therapist by inviting users to input information about their lifestyle, offering tailored educational content, feedback and motivational support.

Numerous scientific studies, systematic reviews and meta-analyses show that digital health behaviour change interventions work. [3, 4, 5, 6, 7] Although social marketing campaigns can help 5% of the population change their behaviours, the meta-analysis by Cugelman et al (2011) showed that digital interventions can help about 10% of the users change the same behaviours routinely targeted by social marketing campaigns.

Beyond their demonstrated efficacy, digital interventions are cost effective when compared to personal support. In the case of smoking, it was estimated that smoking cessation telephone interventions cost $150–$250 per smoker, and tailored print interventions ranged from $5–$40 per smoker. However, tailored online smoking cessation interventions could cost less than $1 per smoker, depending on the size of the population. [8] Given the low cost, broad reach, and proven efficacy of digital interventions, the stage is set to start to seriously consider their wide scale application as a public health facilitation tool.

The limits of digital interventions

Although digital interventions are promising, their capacity to help people comes with several limitations and challenges that still need to be overcome. One obvious limit is that users must have appropriate technologies, such as the latest computer system, mobile phone and a good Internet subscription. As well, users must have the technical literacy to use these systems or be willing to invest the time to learn how to use them.

The research seems to suggest that digital interventions primarily work with people who are already motivated to use them and like traditional interventions, studies show that users drop out of online programs in large numbers, rendering them only effective if used. However, this is similar to medicine. If a person does not take their medicine or the prescribed dosage, they cannot expect to experience its effects. Likewise, most digital interventions have minimum usage requirements, which is similar to a drug’s required dosage.

Digital interventions only work when users enter data into them. If they do not have user data, then at best, they can only be as effective as static content, similar to a print publication. However, with present technology, it is very time consuming for people to continually enter data, and this “hassle factor” is probably one of the chief reasons why there are such large attrition curves on digital interventions.

The majority of digital interventions have not yet mastered kiros, which is the ancient Greek rhetorical principle to present a new idea at the opportune moment, when the target audience will be most responsive. The majority of digital interventions are not good at identifying the best time to intervene, and research shows that automated email reminders are not as effective as some believe.

We are now at a point where sensor technology may soon overcome the data entry hassle factor and enable kiros, so digital interventions know when to engage users, when they are most receptive to change or at risk of relapse. For instance, GPS devices can be used to dissuade citizens from entering junk food restaurants by directing them to the nearest healthy option. Accelerometers can be used to invite people to go for a walk if they’ve been sedimentary the entire day; and galvanic skin response sensors can be used to assess if a person is at risk of accumulating unhealthy stress, and encourage them to distress.

IV Hybrid campaigns that encourage and support change

For someone to change their behaviour, they require both motivation and capacity. Motivation is a person’s desire to change, to achieve something of value. Capacity is their physical ability or skills required to reach that goal, or their self-efficacy, their confidence that they can do it.

Traditional social marketing campaigns employ mass-media advertising tactics to reach citizens. Digital interventions deploy interactive technologies (websites, email, mobile application, sensor technologies) that are designed around a counsellor-patient type relationship, that may run over the course of several weeks. While social marketing campaigns are more suited to motivating people to change, digital interventions are better suited to providing support, joining people as they build the skills and confidence required to make difficult lifestyle changes.

Both approaches are complementary, and should be combined more often as mass-interpersonal health behaviour change campaigns where a mass population is provided interpersonal support. By this vision, the next generation of public health campaigns will still use mass-media channels to engage and motivate citizens, but then encourage them to use interactive technologies to help develop new lifestyle habits. This is similar to the distinction between the advertising used to attract people to a quit smoking program, and the actual treatment with the therapist. However, in the hybrid campaign model, the therapist is an interactive technology, which may also include limited human interaction at key moments.

Given that social marketing campaigns can influence about 5% of a population’s behaviours and digital interventions can influence about 10% of their behaviour, mass-interpersonal hybrid campaigns could theoretically achieve an additive effect of 15% change in public health behaviours.

If hybrid campaigns could routinely achieve this magnitude of behaviour change among populations across a range of health behaviours, then there is no question that interactive technologies could be a big game changer for public health promotion and facilitation.

At the same time, perhaps it’s just a matter of time before doctors start writing prescriptions for “digital medicine”, where persons who are at risk of developing chronic conditions are urged to enrol in online health behaviour change programs, to manage their weight, diet, mental health, and overall wellbeing. Corporations and insurance companies are already using these systems to reduce staff sick days and insurance payouts. Now we will have to wait to see when nations take these proven technologies forward.

About the author

Dr. Brian Cugelman has had an extensive career as a social campaigner, digital strategists researcher, and program evaluator. He has worked with grass-roots organizations, leading non-profit organizations, and has spent over seven years working with several United Nations agencies.

He works as a consultant for AlterSpark Consulting ( where he provides social research, helps organizations measure their impact, and designs online campaigns.

V Resources

Online Interventions for Social Marketing Health Behavior Change Campaigns: A Meta-Analysis of Psychological Architectures and Adherence Factors

The Dimensions of Web Site Credibility and Their Relation to Active Trust and Behavioural Impact

The psychology behind websites that can change people’s health behaviours

Presentation on the Social Psychology of Social Media