Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put

16 thoughts on “Why wearables don’t work and people don’t floss their teeth”

  1. “…fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.”

    Doctors are human so they are influenced by emotion, not thinking. But you won’t find many who admit to this or how to reconcile this fact in an evidence based system.

  2. Good point David,
    The answer to most problems that involve GPs is said to be ‘education’.
    That’s nonsense . It’s much more involved than that and needs a similar approach to changing behaviour in any other group. If GPs don’t see the data to indicate change is necessary and or don’t accept their role in change or perceive that change is impossible then it won’t happen.

  3. This commentary is delivering a clear call for understanding the role of disruptive tech. Health and behaviour related tech is differentiated from other tech developments, such as gaming and general smart phone / online presence, in that the intended outcomes are require effort on behalf of the participant. There is some connection, in my view, to the notion of instant gratification (such as in gaming, social media connectivity, etc.) where the benefits to health are using tech to deliver outcomes that rely on delayed or diminished gratification and associated effort. Therefore the way that such health related wearables will work as intended may be to connect the two.

  4. Thank you Mark,
    For some people turning their health into a game which can be played on a console might lead to benefit. For many others that approach is just too tiresome in the context of their lives.
    I suspect the issues are more fundamental than that. If we want technology to make an appreciable difference to people’s healthcare than it has to fit seamlessly with the way they access healthcare. So, if technology can carry out surveillance to address an issue that I am really unhappy about and that I feel I can do something about then it will make a significant impact because in that teachable moment the software will be providing a trigger. Our team is working on something in that context.

  5. Thanks Marion,
    Perhaps even more than that the problem we face is not being aligned to the hearts and minds of either partner ( patient or practitioner) in the healthcare partnership. The why for one group is not the same as the why for the other and that means we are not on the same page.

  6. Frankly, the paragraph here really resonated with me as an individual:

    ‘Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal.’

    I’m one of the anomalies as I have worn my FitBit for nearly two years. In fact, I left it on the charger at home today and I feel slightly frustrated that all the walking I’ve done today will not be counted! But I do see colleagues and people around me who are gaining weight, year-on-year, and it does make me less concerned about my own body weight, when in fact, I do need to keep working to counter increasing age and reduced activity levels. What I need to do is look more at the body in the mirror rather than the bodies in the lunchroom.

  7. Thank you Deborah,
    it was very generous to share this perspective.

    You are not alone. This is true of most of my patients other than a handful of individuals who adopt FitBits or myfitnesspal for years. These devices are indicated or at least effective in a very small proportion of people. If we prescribed drugs in the way that these things are promoted everyone would be on Prozac, Statins and HRT- and of course you know the story of those.

    A couple of our students have just completed a very elegant study in which they have demonstrated that the overweight and obese almost become blind to their condition. That’s not to say they should worry incessantly about their weight but it appears that their perceptions of their body shape becomes significantly blunted. To these individuals as you are suggesting strategies aimed at adherence to a diet and exercise regimen is challenging.

    1. This illustrates a fundamental problem in medicine – we invest billions in biological research but peanuts on how to deliver wonderful new treatments. This is because there is a failure to recognize that life sciences and all the non biological sciences are now basic sciences in medicine. Neither practice nor medical education recognise this

  8. So from Moyez students research it comes back to Marks comment about combining healthcare wearables with healthcare benefits.
    If healthcare wearables can provide surveillance as Moyez’s team is working to show, then trends/data will show the person they have a problem. Okay the issue here will be to then get the person to accept the problem. However the surveillance with analysis may show the root causes of their problem. Then the person can see what behaviours need to be worked on to improve their health. This is using scientific problem solving methods, which unfortunately as Mark states does not provide instant gratification but does breakdown what needs to be worked on for each person.

    1. Thanks Tracey,
      challenge is that the mode of surveillance is not accepted or acceptable. It is seen as intrusive and often provides information that is not palatable. Therefore the baby goes out with the bath water.

  9. Do wearables work? I guess it depends on your goal. I see one of the main benefits of them is initial awareness. Many people have no idea what their actual activity level is until they take the time to track it. Using a wearable device to figure out how active you are on a regular basis is a pretty eye-opening exercise – at least initially. It’s also great for mapping out what the exertion is on some of your “regular routes” – like your favorite hiking trail. It was quite an unpleasant surprise for me to learn that mowing my lawn was only between 5 – 6,000 steps and that to hit a goal of 10,000 I still needed to take a walk. Does this mean I will wear my fitbit every time I do anything? No, certainly not. I have used it on and off for years now. I do find it motivating to wear when I go through a phase of needing to “get back on track” with my activity and I find it particularly fun when engaged in a group challenge – leaderboards with your peers steps displayed are very motivating to me. Again, would I compete like that daily on an ongoing basis? No. But I find it fun and helpful when I do. I think one has to keep in mind what the goal is when deciding if these “work” or not. It works for me in the way I choose to use it. It should not be used to spy on your employees – and frankly there are too many ways to game the system there to make that even a plausible goal for an employer.

  10. Thank you Cheryl,
    I suspect for some people these technologies are a help- sometimes. But for many people they are yet another $100 worth of toys that never make any impression on their behaviour or their waist line.

  11. I was a little worried when I saw the title of the article, especially as I will soon be attending a conference on wearables and digital innovation in healthcare! However, I completely agree, wearables, by themselves do not work. They provide data and information to help guide decsion making for those who are already in the “right frame of mind” to make changes but they don’t make the changes themselves. I wonder how many people buy wearables and truly think that alone will “fix” their issue? I suspect it’s a lot, and I expect that the marketing departments for those items know that. Humans seem to always want a “quick fix”. I’m not being judgemental, I am one of those humans!

    Wearables may just be the first step, adding in gamification or some visualisation of the future you if you continue on your chosen path might help. Ultimately, it’s about using technology to address items/issues we may not have been able to address before and putting choice in the hands of people at the time when it will make the most difference…when they are ready for it.

    Thanks for the article!

  12. Dear Laura,
    You are right! We should be worried because wearables may be a false dawn. Nonetheless for some people they do trigger helpful behaviours. I suspect it is really important to note that wearables do not MOTIVATE people they TRIGGER those who are already motivated.
    Thank you for your kind comment.

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