App Assisted Behaviour Activation In Healthcare: Part Two
Welcome to the Bitjam medical health app blog series. Last week we discussed the increasing number of apps available on the market, how HCP’s are dealing with conformance and compliance and the effects of app technology on interoperability in healthcare today. If you missed it or want a chance to refresh your memory you can find part one here.
Part two will investigate the technology designed to help patients change behaviours based on Prochaska & DiClemente’s ‘Stages of Change’ model, and the difference between informing and changing – striking the balance between giving accurate and useful information
Many of you reading this article will have first hand experience of trying to change certain behaviours, whether that’s by exercising more, eating more healthily or spending more time relaxing. We know that these changes in behaviour don’t happen overnight, but over a period of stages beginning with precontemplation and ending in action maintenance. As we know, maintaining the changed behaviour so that it becomes normalised day to day rather than short term is very tricky, and in many cases relapses occur, that’s if the idea even makes it beyond the precontemplation stage.
The Stages of Change Model
Different to a theory, this is a model and highlights the various stages and states of behaviour change. It’s also known as the Transtheoretical Model.
- Precontemplation – the earliest stage of change consideration. It can take around another 6 months to take any action during this phase. More often than not people will emphasise the cons here rather than the pros
- Contemplation – also known as the recognition stage, this is when people start to see how adopting healthy behaviours could have an positive impact on their wellbeing and might consider action in the next 6 months, but are perhaps likely to still feel ambivalent to the idea of change
- Preparation – people are ready to take action within the next 30 days, perhaps by taking small determined steps to assist behaviour change. They start to realise that healthy changes could make them happier
- Action – people have recently changed their behavior and intend to keep moving forward with their healthy habits
- Maintenance – people have sustained their behavior change for more than 6 months and intend to maintain the behavior change going forward. This stage is where the work to prevent relapse occurs
- Termination – this is the final stage of the model, in which people are sure they will never return to their unhealthy lifestyles. This stage is very elusive, as most people will always stay in the maintenance stage, working continually to manage their healthy behaviour but still at risk of relapse.
How Technology Can Assist Behaviour Activation
The role of technology not only aids the initial action stage but can support maintenance and deal with potential relapses. As the model in figure 1 suggests, during the stages of change, relapse, exit and re-entering between Determination and Maintenance is a common occurrence. People need as much support as possible to stay – or return back to – the track.
Yet it’s not about how sophisticated the tech is, the key to success is in cracking the psychological obstacles indicated in the Transtheoretical Model, changing the mindset of the person and supporting then offering continual support during maintenance.
Technology is offering a new fix for one of the most confounding health-care challenges: getting patients with chronic disease to take better care of themselves.
This quote perfectly demonstrates the challenge faced by developers of digital health apps. As well as the technical complications – such as data privacy, regulations and synchronisation with older systems – the developer has to present the user (who will now be in the preparation stage”) with compelling language and data that will convince them to move forward into action. The developer will need to have a thorough understanding of the difference between informing and changing, depending on the intention of the app.
The Transition from Informing to Changing
Informing is simply passing useful information on to somebody that’s relevant and beneficial to their treatment, but changing is the act of using this information, implementing the learnings and actively applying the treatment in order to provoke positive and longer lasting behaviour changes. Changing is the activation of positive behaviours. The app must strike the balance between giving accurate and useful information in the most appropriate way and at the right time. This is why understanding the Stages of Change Model is crucial to the performance of a digital health app, the developer must know where their user currently sits in the model.
How Apps Can Actively Assist in Behavioural Activation
- They are more readily available to the patient, using device platforms that they are likely to carry around in their pockets
- The user has 24 hour access
- The user can monitor their progress, which can stimulate positive mentality towards healthy changes
- Accessibility promotes patient empowerment, provided the developer has also considered the challenges of accessibility to those with disability, lack of computer skills etc. Inclusivity needs also to be at the forefront of development
In part three we will be talking with Lisa Sharrock, CBT therapist and registered mental health nurse for North Staffordshire Combined Healthcare NHS Trust, and Bitjam partner to discuss our project BeAble – a post-discharge app currently in phase two of BETA testing designed to assist with relapse-prevention support.
To find out more about digital health apps or discuss your own healthcare technology project, you can make an appointment here to pop and see us at our new location at Keele Science and Innovation Park.
App-assisted Behaviour Activation in Healthcare: Part One
Digital health apps offer new technologies to help a growing and aging population self-manage increasingly complex conditions and comorbidities. Patients demand empowerment to enable them to manage their treatment more independently. Such developments, from the very straightforward to more indepth solutions, can result in lower treatment costs to the patient and the NHS.
This series of blog posts will focus on behavioural activation and the way that the adoption of digital health applications can assist with such an approach to treatment. We will consider:
- the rise of app-reliant health support – how Healthcare Professionals manage and navigate through the apps available, clinician prescribed VS patient choice
- how developers build apps that conform to standards
- the difference between informing and changing – striking the balance between giving accurate and useful information
- providing the means to help patients change behaviours based on ‘The States of Change’ model
The first part in the series will focus on the increasing number of apps available on the market and how HCP’s are dealing with this.
Conforming To the New Norm
Smartphones allow the industry to create apps that are an extension of patient treatments, outside of the doctor’s surgery. They’re designed to push the right information to the right person at the right time.
App developers must conform to health app criteria as outlined by gov.uk. There must be evidence that the apps improves outcomes for patients and users, provides value for money, meets user needs, and is stable and simple to use.
“All apps must be clinically safe: this means that they they’re safe for people to use – not just for healthcare professionals and patients but everyone involved in creation, testing and approval of the apps.”
Apps must capture and handle data sensitively, legally and securely, and usability and accessibility must be considered to mean the app is inclusive of those with disabilities or those with a limited technical knowledge.
Should Healthcare Providers Prescribe Apps or Let Patients choose? Or both?
On the other side of the coin is the recommendation and administration of such apps from HCP’s. The NHS released the NHS Apps Library last year, accessible to the public to help them make informed choices about the apps they choose. This is the one of the early stages of patient empowerment during treatment as the notion of choice stimulates positive behaviour activation.
HCP’s can refer to the Apps Library to help provide better informed recommendations, as each app has been quality standardised and is compliant according to the NHS.
Some apps are labelled, NHS Approved meaning those select few meet NHS quality standards for clinical effectiveness, safety, usability and accessibility and are backed by strong evidence supporting improvement of patient outcomes
However with over 165000 health apps currently in circulation in app stores it’s equally as easy for a patient to “self-diagnose” which can of course present many dangers.
Some HCP’s remain reluctant to adopt their use in clinical practice
– NCBI Mobile Devices and Apps for Health Care Professionals: Uses and Benefits
The vast majority of digital health apps available from app stores aren’t certified by the NHS, therefore they’re without the thorough understanding of risks and benefits. A patient might discover an app that they’re confident will assist with their treatment. The purpose of an app is to provide quality and safety with accurate information and guidance to the end user in order to improve patient outcomes, but unlike medication such treatments aren’t scientifically measured, so if it’s not approved by the NHS, it’s generally at the HCP’s discretion whether to approve its use for their patient, which can be problematic.
Disruptive. In a Good Way
Mobile Health – AKA “mHealth”- has notable benefits globally, especially in developing areas of the world. Countries such as Africa are emerging with “ a great deal of innovation, because the need for low-cost solutions for pressing health issues has generated much experimentation and research that is likely to play a role in more advanced economies in the coming years
– Gigaom
The distribution of a physical pill as part of a patient’s treatment, despite rigorous scientific testing, can still never assist with certainty in improving patient outcomes. As the world becomes immune to antibiotics it seems practical and imperative that another solution be brought to the doctor’s office. Unlike traditional medication, mobile apps have greater potential to assist with behaviour activation, as it encourages the patient to educate themselves by becoming actively engaged with a non-invasive treatment method.
Interoperability
In a previous blog post we discussed interoperability in healthcare and why electronic data such as EHR’s need communication improvements in order to function more effectively. We also discussed the NHS at 70 and the ways in which digital can be adopted into the wider healthcare sector to ensure another successful 70 years of the National Health Service.
“Interoperability is the extent to which systems and devices can exchange and interpret shared data. In healthcare, effective interoperability occurs when IT and software systems exchange shared data to create information that can be used to assist clinicians and other medical professions with patient care.”
Digital health apps have the potential to improve interoperability, as longer as there’s focus on training efforts, and apps that need to communicate with clinical systems must be compliant with the relevant technical standards.
At Bitjam we’ve recently developed an app called BeAble, with Combined Healthcare that bridges the gap between one-to-one appointments and discharge, enabling mental health patients to effectively manage their aftercare without the need for more appointments. The app is in phase two of testing, and each user has been given adequate training to use and administer it to the patient. Find out more here.
Next week we’ll be following up with a discussion about the difference between informing and changing patient outcomes, providing the means to help patients change behaviours based on The Transtheoretical model.
In the meantime if you want to discuss any of the matters surrounding patient empowerment, behaviour activation and digital health applications drop us an email for a chat.
Carl Plant, Bitjam Director
Name: Carl Plant
Position: Director at Bitjam
Carl is a director with a unique skill set. He originated as an NHS practitioner, with a background in creating technology and software applications, from web development to building high-impact and secure software solutions for public sector organisations. As director of Bitjam, Carl fuses his experience in frontline healthcare with his avidity for technology and a passion for creating solutions that have social benefit.
How did you merge your experience as a healthcare worker with your enthusiasm for complex software development to found Bitjam?
Most of my earlier digital work was building websites and applications, using very early – almost primitive – technologies compared to today. Much of my early work, especially in health and data visualisation, I began to share through a blog. I then got involved in the open data movement looking at ways to turn data from spreadsheets into stories or applications such as maps and graphs.
During early 2005 I was successful in getting the position of National Development Officer (NDO) for the UK Association for Solution Focused Practice (UKASFP). While developing the platform and building an online community I got the chance to develop a website for an NHS Mental Health Crisis resolution team. Soon after I began to work on numerous digital projects including an online support platform for people with learning disabilities which tested the ability to build accessible web applications. Meanwhile my datablog was attracting support, presenting opportunities to present and consult with the Royal College of Nurses, National Institute for Healthcare and Excellence (NICE), Nursing and Midwifery Council, marathon open data hacking sessions at The Guardian plus numerous health data hack sessions around the UK.
What advantages did this experience give you to develop Bitjam in to a niche software solutions company for public sector organisations?
Over the years I’ve led on many digital projects in the public sector, working through the challenges of creating a solution that solves the problem at hand, rather than making a solution fit a problem. Understanding the barriers to adoption is a key learning point, using an agile approach that works closely with the end users, and not being afraid early in the project to reject assumptions.
Bitjam prides itself on working with organisations and projects that have a social benefit. As director, why is this important to you?
I used to work in a company that made wiring harnesses for the military, I left this career to work with people, to make a difference to society and that need has stuck with me. This led to working with those with learning disabilities, then on to Mental Health as a nurse after going back to University. This need to do good remains with me today, I’m driven by the desire and understanding that digital technology can improve the lives of people. I see lots of companies who only see health tech as a commercial opportunity and you can see the effect that has on the products, when they don’t achieve the desired outcomes. I believe I can find the balance between creating a strong business while achieving good outcomes for society.
Bitjam’s tagline is “Developing technology from small ideas to global growth”. How do you achieve this using co-production techniques and agile methodology?
We work in partnership, walking side by side with our partners. I guess it’s my nursing experience that allows me to listen and develop equal relationships with clients. I believe the clients and the users of a digital services are the experts in their sector or life experiences and we need to tap into that rich resource. This isn’t always easy especially when working with marginalised groups, or people who have accessibility barriers to breakthrough.
We have expertise in how technology can be wired together and deployed, we can only create success by working in this close relationship with a shared set of goals with the users of the service.
I believe it’s important to allow flexibility in the development process, to allow testing and revision, and crucially, to allow your assumptions to be challenged.
After spending many years working with technologies and keeping on top of newer stable versions, and importantly having fantastic staff, we have the ability to launch solutions to scale, in some cases taking them global.
What do you think is crucial for digitalising the healthcare sector in the future?
Sometimes the best solutions are simple, they perform a singular task and perform it very well. We see the opportunity for emerging technologies like AI, VR etc. These will only work if they are designed for a specific purpose and not off-the-shelf solutions designed for other sectors bent to look like it solves a problem in health. Also as Clay Shirky once said, “Communications tools don’t get socially interesting until they get technologically boring”, this is true with many technologies.
We must not shift our focus too heavily on new technology and forget that older technology such as SMS and MMS provide perfect means of building effective solutions. Lastly, we have been sidetracked by Big Data and having been overlooking small data we use daily in datasheets, databases etc. We have yet to fully harness small datasets, and we need to continue connecting systems together. I believe the work that NHS Digital are doing to improve interoperability is key.
If Carl’s history and experience are suited to your own healthcare technology project, you can get in touch by sending an email here. He’s always got the kettle on!
