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Four ingredients for innovation (in rank order)

1.People want to retain their youth, remain potent, be connected and yet products which ultimately harm what people value are being successfully marketed. People buy these products believing the promise of youth and glamour. Health promotion will pass mustre when their boring message is translated from what you can ‘prevent’ that seems to you unlikely (cancer) to what you can retain or regain that you value at a primordial level.

I want it.

Question for innovator: Why would anyone choose to act on your promise above some other that also promises youth, potency and or social connection?

2. Deliver messages about your product by someone the person trusts – ideally the person themselves. Messages that are deposited deep behind the person’s psychological defences are highly effective. Such messages are especially potent when they appear to come from what the person perceives to be their future self.

It’s about me.

Question for innovator: Can your quarry clearly see themselves in the story of  your product?

3. Make the user of your product a hero. Persuade him that he can have or do something that will make him feel and or look very good, very soon. Something that he did not think was possible but is now with your help within his grasp.

I will feel good very soon.

Question for innovator: How does your product make the target feel good?

4. Talk about your ideas when the recipients are ready and willing to hear them. Ideally not when you are competing with other things that the customer, client or patient considers urgent and important.

I hear you.

Question for innovator: Why should the customer choose your product now?

Each of these is a necessary but not sufficient ingredient for successful innovation especially in health care.

Picture by tec_estromber

A lens for new ideas

3168683736_304641aa66_zLast week our team  published a paper exploring the scope to improve the advice offered to patients (i.e. to change the behaviour of the practitioner). We focused on people with dementia who present with challenging behaviours because so much more is on offer to patients living with this condition than is promoted by doctors. The team explored the practitioners’ perspective on the issues with reference to simulations. Referring back to Lewin’s equation, B = ƒ(P, E) i.e. behavior is a function of the person in their environment.  Professional behaviour change is also subject to Fogg’s model  so behaviour is a function of motivation, ability and trigger (B=MAT).

In addition any consultation with a health care practitioner motivation is highest when the practitioner is:

  1. Rewarded for action (A) in those circumstances.
  2. Able to act within the time (T) available
  3. Has the scope to reduce risk (R) to the patient but also the risk of litigation or complaint

M = A+T+R

The ability (A) to do the needful is a function of:

  1. Cost (C) of the treatment or intervention
  2. Effort (E) required to access it

A = C+E

Finally the Trigger (T) to adopting the requisite behaviours are determined by:

  1. Recognising the patient (P) for whom the action is indicated
  2. Knowing (K) what is available in the circumstances


With this lens our data suggests that an intervention to increase referral to community support agencies (the desired behaviour) should consider the following:


A: Some participants in the study expressed the view that care coordination would be unrewarding.

T: This was not specifically explored in relation to these scenarios however it is possible, that people presenting with such problems to a doctors office would require more time than is available in short primary care consultations.

R: Feedback to the practitioners on individual scenarios highlighted the risk of medicolegal consequences of a failure to act. There was a marked improvement in the proposed management plans when this was pointed out.


C: There was no cost to the practitioner or the patient in making a referral to a community support agency. However practitioners expressed the view that care coordination in this setting is ineffective.

E:In many cases it was considered difficult to coordinate the care of patients with behavioural problems in the context of  a dementia diagnosis, however the level of difficulty was not a factor in the decision to coordinate care for this group of patients. The data also suggests that older practitioners were more cynical about their ability to coordinate care.


P:Some scenarios where the scope to assist was apparent were not recognised.

K: When practitioners were made aware of what was available to them, they were more likely to act.

Therefore an intervention that could promote referral to community support agencies for people exhibiting behaviour change in the context of dementia would have all of the following characteristics:

1. Emphasise the responsibility of primary care practitioners to act in these circumstances, including the medicolegal consequences of a failure to act.

2. Make it easier to find and refer to voluntary and statutory support agencies and

3. Where the motivation and ability has been optimised include reminders that specific patients would benefit from support – for example the driver whose cognitive function is a risk to other road users.

Picture by nhuisman

Are ‘triggers’ the best health innovation?

9212656123_07027098e1_zPrimary care practitioners are expected to achieve a lot in their short interactions with patients or clients. The limited time available has a significant impact on satisfaction, outcomes and patient safety. In this context the question of developing innovations to support people to adopt different choices and reduce risk of chronic diseases, improve well being or reduce morbidity warrants careful consideration. The challenge is to innovate for impact on problems that are multidimensional and may be difficult to address with a ‘magic bullet’. There are many examples of topics that have been advocated as the purview of primary care practitioners they include-promoting weight loss and smoking cessation, reducing salt consumption, advocating safe sex, discouraging teenage pregnancy, encouraging exercise and a host of other issues where ‘prevention’ is touted as the best solution. Occasionally ‘health promotion’ in primary care is encouraged with financial rewards where time pressure is already a concern. In reality the evidence for health promotion in primary care is equivocal. Secondly and perhaps more to the point the drivers for behaviour change are more effectively addressed through taxation, legislation, public health campaigns, non government organisations, schools, parents and the media. Nonetheless when the rubber hits the road and a person develops early signs of chronic disease there is an opportunity to encourage that person to address the risks, albeit that nothing can guarantee longevity or good health.

At an individual level how do you activate behaviour change in people who just won’t seem to budge? For effective behaviour change three things have to occur at the same time:

1.   the person must be motivated

2.   the person must have the ability, or perceive they have the ability, to take action

3.   an appropriate trigger (or prompt) must be applied.

Without all three behaviour will not change.

Motivators are those which are an inherent part of the human experience everywhere:

  • sensation – pleasure/pain
  • anticipation – hope/fear
  • social cohesion – social acceptance/rejection

Of these, probably anticipation, is the only one which might conceivably be addressed relatively quickly. However:

Evidence of a direct correlation between risk perception and self-protective behavior is ambiguous at best. Rimal and Real

Recanting warnings about the dire consequences of persistent alcohol abuse are unlikely to result in abstinence in the vast majority of cases.

Ability may be even more problematic. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. In practice medical practitioners may struggle to achieve this in the context of a busy clinic. Enhancing a patients ability to control their weight for example means making it easier for that person to eat just enough. Michael Wu, breaks ‘simplicity’ down further, he identifies:

  • effort resources (physical and mental effort)
  • scarce resources (time, money, authority, permission, attention) and
  • adaptability resources (capacity to break norms – personal/routine, social, cultural)

In reality this can rarely be achieved within a few minutes in a medical consultation. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. Fogg offers the following insight:

Simplicity is a function of your scarcest resource at that moment. Think about time as a resource, If you don’t have 10 minutes to spend, and the target behavior requires 10 minutes, then it’s not simple. Money is another resource. If you don’t have $1, and the behavior requires $1, then it’s not simple.

It may be the reason why it has been tempting to issue prescriptions in response to lifestyle related risk factors for chronic disease . However pharmacology is yet to solve all of mankind’s problems. That brings us to triggers. Fogg defines three kinds of triggers for three different contexts:

  • sparks – a motivating trigger, applied where there is high ability but low motivation
  • facilitators – enabling triggers, applied where there is high motivation but low ability
  • signals – a prompt, applied where both motivation and ability are high

Therefore within a primary care context a trigger could be efficiently delivered to some people. For example it has been demonstrated in Australian primary care motivation is high:

Fifty six percent of patients intended to lose weight in the next six months. Females, younger patients, those with a level of education of trade certificate and above or those with high cholesterol had significantly higher odds of intending to lose weight. “Health” was the top reason for wanting to lose weight in normal weight (38%), overweight (57%) and obese (72%) patients. Yoong et al

On the other hand ability may be limited:

Australian consumers have a poor understanding of energy and kilojoules and tend to perceive higher energy products as healthier and providing sustained energy. Watson et al.

Therefore in this context an enabling trigger or prompt may be effective. An innovation can underline ‘why’ to someone who knows ‘what’ and ‘how’, even if it means stimulating them to find out how. Here’s one that worked for us for a similar problem. Finally, and to reiterate, innovation has to be easily adapted into the workflow in primary care as per normalisation process theory.

Picture by Nottingham Trent University

Removing the triggers to unhealthy choices

Much of the work in medicine is persuading people to give things up; tobacco, fizzy drinks, junk food, alcohol. Health professional also need people to do things- take medication, have surgery, keep appointments, exercise and so on. An entire industry profits on persuading people to make such choices and on helping doctors to sell more effectively. BJ Fogg has distilled such business into a simple equation.

My Behavior Model shows that three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. (Behaviour= Trigger+ ( Motivation+ Ability)

Our health and well being depends on how effectively doctors can do this. Notwithstanding that medicine hasn’t always got it right. Not that long ago doctors were trying to persuade people to take up smoking. Perhaps something like this could happen again, but I digress. The point is that health professionals are in the business of selling health messages, services and treatment. Last week I raised concerns about how some elements of this industry has taken to offering data as the key cue to action. Data elicitation and display has become a very profitable business. This week I explore this issue with reference to obesity.

It is often assumed that people make decisions about food and eating in rational conscious ways. However, if this were so, the obesity epidemic would not be happening. People overconsume in response to environmental cues and they lack insight into the extent to which their food choices and eating behaviors are being manipulated by sophisticated advertising and marketing techniques. They also have a limited capacity to sort through the increasingly overwhelming mountains of information and claims about food choices and, as a result, too often choose default option foods high in fat and sugar that, when consumed routinely, lead to chronic diseases. Deborah A. Cohen

So the challenge is trying to persuade people to eat less or at least less often. I offer four pieces of empirical advice to any of my patients who wants to lose weight some of which has come from the extensive review by Cutler, Glaeser and Shapiro:

1. Don’t put anything in your mouth while standing up other than a tooth brush-based on the observation that people consume a lot of calories while preparing food or snacking on the move.

2. Don’t eat other than at a dinning table- people often eat at their desks or worse, in front of the TV.

3. Don’t go shopping when you are hungry- it tempts you to bring things home that will sabotage your efforts to reduce consumption.

4. Don’t eat between meals…Duhhh!

Foggs Behavior Wizard suggests that to persuade people to decrease a behaviour:

  1. Remove the trigger that leads to the undesirable behaviour
  2. Reduce ability to perform the behaviour (make it harder to do)
  3. Replace motivation for doing the behaviour with de-motivators:  pain, fear, or social rejection

So the trigger that leads to the undesirable behaviour is the feeling that you are ‘hungry’. What Fogg recommends is:

When you design for persuasion, you don’t start by manipulation for motivation. That’s what you do last.

Therefore targeting motivation through calorie counting or calorie expenditure isn’t going to work. There are too many hours left in the day after you’ve consumed the few calories you need to lose weight and you have to do an unrealistic amount of exercise to be able to consume more. The real  problem is that people misinterpret four emotions associated with the urge to eat:

  1. Hunger
  2. Thirst
  3. Boredom
  4. Unhappiness

Therefore the trigger is often unrelated to the need for food and more to do with something else that hasn’t been acknowledged. To remove the trigger it must first be recognised as false. Therefore you might substitute or associate with another established trigger – namely answering a mobile phone or checking for email or facebook updates. By associating the urge to eat with checking an app on their mobile phone the person can work out if what they really want is food or something else. To reduce the ability to perform the behaviour (eat that popcorn, cake or choclate bar) the person needs to remove themselves from the place (physical or psychological) where the behaviour takes place- in front of the TV, at their desk at work or on the concourse at the station. This means either finding a new hobby, making a habit of only eating at a dinning table or carrying a bottle of water to and from work. Finally replacing the motivation for doing the behaviour with de-motivators could be part of the proposed solution by offering a diary of the poor choices that have tempted the individual between meals. I look forward to sharing a solution soon. Wearable not required.


Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?