The Center for Total Health (@KPTotalHealth) is Kaiser Permanente’s Social Innovation Center.
This presentation was given to the American College of Preventive Medicine (@ACPM_HQ) Corporate Roundtable, meeting in Washington, DC, to introduce the Center, Social Innovation, and Total Health for individuals and communities.
I also included a little information about the “Why” of prevention at Kaiser Permanente. Thanks to a little help from our friends at the A History of Total Health (@KPHistory) blog.
Thanks for having me!
Facilitating: Livable Communities : Healthy Neighborhoods National Building Museum.
An honor to facilitate:
- Scott Ball, planner with Duany, Plater-Zyberk & Company
- Terry M. Bellamy, mayor of the city of Asheville, North Carolina
- Irene H. Yen, PhD, MPH, associate professor, University of California, San Francisco
Studies show that our homes and neighborhoods play a large role in public health, especially for an aging population. Walkable, safe, and connected communities promote exercise, access to healthy food options, and an active social life. Panelists discuss how planning, design, and community engagement help create livable communities for older adults and everyone.
September 12, 2013, 6:30 pm – ticket purchase required (support the National Building Museum) @BuildingMuseum
#PreventionisthenewHIT – see you there
Route: “The Citizen” (click to enlarge) Get this app here
Route: “The Presidential” (click to enlarge)
This is just one of the photographs I tend to enjoy taking of people engaged in active transportation, while I am engaged in it as well, and usually in my favorite place, the most walkable city in the United States…..Washington, DC.
And now, it’s easy to track your walk quickly, and frictionless-ly with the relaunched Every Body Walk! (@everybodywalk) app, available for Android and iOS.
When you download and use it, you’ll see what I mean. When you are on the move, it’s hard and unrewarding to spend time tending to your smartphone for tracking purposes, and this redesigned app doesn’t make you do that. There’s just a big huge button that says “Start”. Press it, and keep going.
The sharing part is really easy, too. This comes in handy when you are going on a walking meeting (which you are doing, aren’t you), and it’s helpful to share with the person who you introduced this to (you are introducing walking meetings to others, aren’t you) how you did, where you went etc.
My approach is to walk a different route every morning, depending on how many social determinants of health I would like to study. I’ve named my routes accordingly in the images on the right. Feel free to do the same and post your results – tag them #activetransportation.
Here’s a gallery of past routes / images I’ve taken. Isn’t Washington, DC, beautiful?
Prevention is the new HIT.
Photos of/from #activetransportation
Spring B, Schneider K, McFadden HG, et al. Make Better Choices (MBC): study design of a randomized controlled trial testing optimal technology-supported change in multiple diet and physical activity risk behaviors. BMC public health. 2010;10(1):586
The quick answer is: don’t focus on the technology.
This is not one, not two, but three papers published in the last six months, the last one last week, encompassing an impressive body of work around behavior change and weight loss, from the same research group led by Bonnie Spring, PhD, at Northwestern University.
There’s a lot of stuff in here – everything from financial incentives to the way you coach people about behavior change to the use of mobile devices. If you don’t read them all (or don’t read any of them all the way through), it’s highly likely that you’ll come to the wrong conclusion, in my opinion, so I’m going to break it down here:
1. The way you counsel people about behavior change makes a difference
This is actually the most important part of the first two papers linked here, not the up to $730 incentive (more on that later). What the authors studied was competing theories about how to talk to people. They looked at four different ways, which I’m going to summarize, because it’s important – these are things that are cost-free and don’t require any capital expenditure to deploy 🙂
- Theory 1: Familiarity hypothesis, I’ll call it “MOTS: More of the Same” – “Decrease your saturated fat intake, increase your physical activity”
- Theory 2: Behavioral Economic hypothesis: Crowd out an unhealthy behavior with a heathy one – “Eat more fruits and vegetables, decrease your sedentary activity” <- This was the winner
- Theory 3: Low Inhibitory Demand, I’ll call it “Don’t be a downer, tell people what they CAN do rather than what they CAN’T” – “Eat more fruits and vegetables, increase physical activity”
People coached with the winning theory had significantly higher changes in a calculated “Diet-Activity” score compared to others. If you break it down a little more, it looks like it was far more likely that they could eat more fruits and veggies, than that they could increase their physical activity, across all groups. The winning group, though, dramatically decreased sedentary leisure, almost by half, which persisted 20 weeks later.
2. Paying people is a background activity to the above
In the first two papers, people were paid $175 to go through 3 weeks of intervention and point incentives along the way up to 20 weeks of follow up, for a total of $730. It seems like this got them through to recording their information. I don’t think it’s the most important feature of the study, and as the authors point out, probably not a realistic approach moving forward.
3. The mobile technology itself doesn’t help in isolation
Notice, I keep saying “mobile technology” not “smartphone.” That’s because these studies used PalmPilots (!) to support entry of data and target feedback. All of the study participants in the behavior change theory study improved their diet-activity score. There was no control group there, the goal was just to compare the theoretical approaches. The first study relied on self report of food intake and physical activity, which the authors sought to keep accurate by deploying a “bogus pipeline” approach where they told people to submit their grocery receipts and accelerometer data that were actually not used – clever.
The second study, which is in the third paper linked to this post, was more focused on weight loss itself rather than behavior change, and in it, the authors planned at the start that the mobile technology would be part of intensive coaching for all study subjects – they didn’t even try to have the mobile device make this happen for people. And in fact, the mobile device by itself didn’t make it happen for people – the one group who were randomized to get the mobile device and didn’t go to class actually gained weight. They gained more weight than the control group who had no mobile device.
What did happen for people was weight loss when they (a) used the mobile device to track and get feedback AND (b) they went to classes, in person. That was the requirement – that both happen, and when it did, this group lost more weight initially, and kept it off – average of 6.38 pounds at 12 months. The people with the mobile devices that didn’t go to classes, gained about 5 pounds at 12 months, which is more than the people who went to classes by themselves, and more than people who didn’t do the classes or get mobile devices.
There’s another really important piece of information in all of this, which is that the people who were
selected to get mobile devices randomized into the study were selected after a two week trial of recording their information. About 35% of the people that went into this gate didn’t make it, so in the end, this was a study of people who can use mobile devices to record their information.
As I said, there’s a lot here
I’m looking at this from a population/social determinants perspective, and I would ask the question, “Should mobile devices or apps be deployed to the entire population to make weight loss happen compared to other approaches?” The answer for me would be “no.”
I think what the authors are demonstrating is the answer to this question, “Should mobile devices or apps be deployed to people who are motivated to use apps to lose weight and participate in intensive behavioral interventions?” to which the answer is more of a “yes.”
Also, “Should we get smarter in communicating with people, with technology and not, about their choices? – answer is “yes.”
I think we still need to think about technology as an enabler at the right time / place , everyone is necessary, and the hard work of looking at the causes of the causes of poor health is not going to go away (see: Now Reading: Why a focus on lifestyle behavior change may not improve health: The Marmot Review | Ted Eytan, MD).
The reason I love technology and have been invested in it for so long (and will continue to be) is because of its role in facilitating communication and connecting people to people. The best.app.ever is the human brain, the most important innovation in health information technology is listening. Oh, and prevention is the new HIT.
I communicated with Dr. Spring before writing this post to help me understand what we can take away from this research, which is very important/timely/useful (and I of course invited her to Washington, DC to the Behavior Change Summit in 2013 🙂 – More info on that here: Behavior Change: What can we learn from other industries? – EXAMPLES | Ted Eytan, MD). I learned a ton here that I didn’t know before, which makes me happy that talented behavioral scientists are working in this area.
This is the reality of climate change in our cities. At one drug store:
And at another:
Allergy season started 3 weeks earlier than last year. The shelves are cleaned out. You can imagine that the consumers of these products are probably not as productive, happy, or with the same sense of wellness they usually have. To me, this is an image of suffering.
This is not the reality of climate change in our cities, from a display at Reagan National Airport, in Arlington, Virgina
The problem with the iceberg image is that it doesn’t connect people to the impact of climate change in their lives; research has shown that the polar bear / iceberg imagery is less effective in describing a problem that affects people. The drug store image connects climate change to our lives. Images and messages that focus on the impact of climate change to people are more effective, which is I why I wrote this post.
And, it’s a vicious circle. Health care in the United States accounts for 8 percent of our nation’s CO2 emissions. In the United Kingdom, health care accounts for 3 percent. Pharmaceuticals are accountable for 14 percent of those emissions in the US ( 21 percent in the UK ).
More allergies = more medications = more CO2 production = more allergies = more suffering.
More allergies also means more loss. In this great study by Ron Goetzel, PhD, et. al: “Health, Absence, Disability, and Presenteeism Cost Estimates of Certain Physical and Mental Health Conditions Affecting U.S. Employers“- the productivity loss of allergies has been estimated at 0.9 hours a day from an 8 hour work day, with a total cost of $271.04 per employee per year in direct and indirect costs (medical treatments and productivity). The annual cost of diabetes is $256.91 per employee per year. I’ll call these numbers “dramatic.” More allergies also means less physical activity, less resources for people to reach their everyday and ongoing life goals.
I’ve posted my own allergy journey on here previously (See: “Why Health2.0 is a great idea: The Case for Allergies”). I never had seasonal allergies until I moved to Washington, DC. I’ve become incredibly knowledgeable about how to manage mine, but I still move a little slower, take a little more time to get things done, spend a little more time indoors. I now understand why someone with pet allergies might have a cat or a dog. I call this time of the year, “the time that DC tries to reject me,” but I still <3 DC. Love knows no bounds I guess.
Someone might say, “this is good, promoting the health care economy through the production of these medications.” However, the goal of health care is not to put more resources into health care, it is to liberate the resources people have to achieve their life goals instead of paying for unnecessary treatments.
I’ve never been an environmental activist and I don’t see myself becoming one in the future. Probably more of a health activist. Climate change, like the other things I’m interested in, such as diversity, and patient access to information, is a health issue. Climate change, like the other things, is also a social determinant of health. Its impacts, including the ones above, disproportionately affect people across the social gradient.
I really enjoyed putting these together because I learned so much in the process. And I thank the American College of Preventive Medicine ( @ACPM_HQ ) for allowing me to practice it for the first time to an understanding audience.
Slide share version plus click through version below (I like the slide table view so I can go right to what interests me).
I worked to put together all the sources in one place, and you can find those here: