This guest blog is by Dr Max Western. Max is a Lecturer in Behavioural Science at the University of Bath. His expertise includes motivation towards healthy lifestyles, physical activity behaviour change, healthy ageing and the prevention and management of chronic disease. In the last year he has worked with colleagues at the University of Southampton developing digital interventions to support healthy behaviours in older adults, using a person-based approach to design. Max was a participant in the My Healthy Future workshop on older people.
By 2050 the number of people aged 60 years or more will rise from around 500 million to 2 billion. The number of people aged 80 years or more will have quadrupled to around 305 million. Unfortunately, the likelihood of this ageing population enjoying their later years disease-free is very small, with conditions such as cardiovascular disease, cancer, dementia and osteoarthritis dramatically reducing ‘productive’ life years. Indeed, around two thirds of over 65s will have multimorbidity, i.e. more than one condition or impairment. Reduced mobility, cognitive impairment and physical frailty mean that many older adults may have poor mental health, a low quality of life and/or an inability to live independently – all putting further pressure on the already strained resources available to care for older adults.
The story is not all doom and gloom however as there is good evidence that healthy lifestyle behaviours such as regular physical activity, eating a high quality diet and avoiding excessive alcohol, tobacco and other toxic substances can mitigate these conditions, even when adopted in later life. The challenge lies in finding innovative and engaging ways to help the rising population of older adults to stay healthy, happy and independent.
Technology – getting it right
As technological innovations continue to flourish there is a valuable opportunity to develop digital interventions that encourage older adults to adopt and maintain healthy behaviours.
Using digital technology to promote behaviour change offers many benefits – including tailored support to individuals across geographical locations and social-economic status, and an opportunity to overcome mobility barriers and increase social-connectedness.
Having worked on a number of large-scale interventions and undertaken qualitative work with healthy, frail and cognitively impaired older adults in the UK I have come to realise several important considerations for developing digital behaviour change interventions for older adults:
- Behaviour change doesn’t always mean learning new behaviours. Often the biggest barriers to behaviour change are a perceived lack of physical ability and lack of opportunity or drive to try something new [and healthier]. Drawing on past behaviours (which could be seen as achievements) or helping people to realise ways they may be able to incorporate new behaviours into their current lifestyle are good approaches.
- Don’t assume that older people can’t use technology. The number of older adults engaging with technology is increasing all the time. Difficulties in using PCs, tablets and smartphones are often to do with things like text size, navigating through pages or identifying buttons and links – things that are simple to get right at the development stage.
- Tailoring to individual needs and capabilities is critical. Ageing affects each of us differently and a one-size-fits-all behaviour change programme is rarely effective for everyone. Digital technology can be used to gather information from users, for example on current levels of physical activity or cognitive function, in order to tailor the digital intervention to the individual’s needs.
- Our interventions mustn’t stigmatise ageing. It is important when promoting healthy behaviours and communicating risk to not make people feel embarrassed or despondent. Setting realistic behavioural goals and providing targets and feedback that are commensurate with these is essential to help individuals feel positive towards changing their behaviour.
The person based approach to digital intervention design
Overcoming these challenges isn’t always straightforward and many intervention developers can fall into simple traps that ignore the user needs, particularly when excited by an innovative idea.
To mitigate these pitfalls when developing digital interventions, our team uses the person based approach (PBA). The PBA is a systematic approach to intervention design that places the target user(s) at the centre of development. It aims to optimise the acceptability, engagement and appropriateness of a digital intervention whilst making it motivating, informative and supportive of behaviour change.
The two main elements of PBA are
1) Iterative, in-depth, qualitative research with a wide range of target users throughout the development to understand their lives and perspectives and to identify issues that can hamper take-up such as limited mobility, poor social support or inflexible care schedules as well as interpretation and use of the intervention (e.g. does the user understand the guidance).
2) Setting guiding principles that inform development by highlighting design objectives that outline what an intervention needs to do to meet users’ needs and overcome any challenges identified in step 1), and then select intervention features that achieve those objectives. This process should draw on evidence (from a qualitative synthesis of existing literature) so that the most feasible and salient behaviour change techniques, technological features and implementation settings are selected as part of the digital intervention.
Once the intervention is developed then draft materials or a prototype are tested and refined using feedback from users. We like to do think aloud interviews to gauge immediate thoughts and feelings, particularly in relation to how comprehendible, useful and persuasive the content is. Later, we use retrospective interviews to gauge users’ real-world experience of using the intervention and trying the promoted behaviour changes.
For example…
Let’s say we are developing an application to increase physical activity in older adults with mobility impairment. User interviews and the literature synthesis suggest the exercises we are promoting are seen as unfeasible and elicit feelings of inadequacy. Based on this feedback we determine that a key guiding principle has the design objective to promote user competence and self-efficacy, and an intervention feature to help achieve this could be to provide user stories that model successful behaviour and empathise with the emotional experience and a function for setting more progressive and realistic goals with positive, reassuring feedback.
Once we have a usable app, should the ‘think aloud data’ suggest, for example, that users don’t like free text boxes for goal setting and that the app doesn’t provide users with enough structure, we refine it to perhaps include a drop-down menu of realistic behavioural goals and an opportunity to specify exactly where, when and with whom users exercise.
Age need not be a barrier to technology
As the people who use technology in their early years and work life become the next generation of older adults digital interventions will be commonplace in the fight for good public health.
As with all behaviour change interventions the aim of digital interventions is to facilitate lasting behaviours and habits. Given the diversity of individuals, it is critical to understand the target audience so that appropriate solutions are implemented. The person based approach is a valuable, systematic process for developing digital interventions that complements theory and evidence based approaches and, importantly, places the user at the centre of design.