Digital technologies are undoubtedly revolutionizing healthcare. Hundreds of wearable devices, health and wellness apps, digital medical devices, and health websites are launched every year, many of them promising to personalize healthcare, increase patient access, and empower people to lead a healthier, more enriched lives. While the objectives of these new technologies are clear, optimally engaging users in order to yield the desired outcomes is not always easy. Many companies turn to design agencies to help address this issue. We at Medgadget had the chance to interview Dr. Amy Bucher, Behavior Change Design Director at Mad*Pow design agency, to learn more about the workings of design agencies and how they are applying the fundamentals of motivational psychology to the designs of digital health technologies so as to improve user engagement and outcomes.
Kenan Raddawi, MD, Medgadget: Can you explain what design agencies are for those unfamiliar with them? What do you mean by the word design?
Amy Bucher, PhD, Mad*Pow: Design agencies help clients solve problems and develop products and experiences. They may work either on retainer, where they partner with a client over time on multiple projects, or on a per-project basis. The skill sets in a design agency can include strategy, visual design, web and app development, content development and strategy, project management, and client engagement. Some agencies also have differentiators like ours in behavior change.
When we use the word “design,” we refer to much more than the physical appearance of an object or website. Design is the entire process of evaluating a problem space, researching user and stakeholder needs, generating potential solutions, testing and iterating on them, creating the decided-upon solution, monitoring it for outcomes, and iterating on it as you learn. It includes what people normally think of as “design”— making something functional and visually appealing — but also all of the strategy in understanding what that should be and whether it actually succeeds. We can handle that entire process or work with clients to support any component of it.
Medgadget: What is Mad*Pow, and what sets it apart from other design agencies?
Dr. Bucher: Mad*Pow, based in New England, is a full-service design agency with the skill sets and talent to execute all phases of the design process from foundational research, to experience and behavior change strategy, to interaction and visual design, development, implementation and evaluation. Our approach to design is backed by a flexible methodology that includes scientific methods balanced with experience, strategy, creativity, and invention. Our passionate team is consistently learning new methods, trying them, refining them, and teaching others how to execute them, guiding our clients and our industry in new and positive directions. Our unique approach and our successes stem from the high value we place on immersing ourselves in the problem to be tackled and the contexts of the populations we’re serving.
Our goal is to ultimately deliver measurable results and exceed client expectations. We recognize that the success of behavior change is measured through outcomes. Accordingly, we emphasize outcome measurement plans from the initial development phases and work with our clients to clarify meaningful, measurable results. Our strategy includes monitoring both leading and lagging indicators of efficacy throughout each phase of the project and adjusting our approach to optimize the ultimate success of the intervention. Our focus on outcomes goes beyond a traditional design agency: We have also been co-investigators in human subject research and co-authors on peer reviewed publications, particularly through our behavior change practice.
Mad*Pow is a value-driven organization. We believe in using our talents for social impact, which is one reason why so much of our work focuses on healthcare. We are passionate about projects that give us the opportunity to enact meaningful positive change for individuals and communities. We deliberately seek and select projects that allow us to do good in the world.
Medgadget: How do you determine how successful your interventions or designs are at achieving a company’s desired outcome?
Dr. Bucher: We approach this a few ways. We’re always aware of what our clients consider success, and often they have specific KPIs or metrics established that we will work to meet. One of the first steps we take in any project is to review those success metrics with clients and then ensure that we’re working toward them at every step of the design process.
One of the differentiators we bring to the table is that we also focus on clinical and research outcomes as much as possible. We believe that what makes our designs successful is not the number of clicks they receive, but how much they help people make positive real-world changes. We try to work with our clients to measure clinical outcomes as much as possible. An example of that is that when we worked with Joslin to bring their diabetes management program to a scalable digital format, we also tracked outcomes to ensure that 25 percent of participants met the 6 percent weight loss goal.
We also collaborate with academic researchers when we can, and are seeking opportunities to integrate randomized control trials or other high quality evaluations into our designs.
Medgadget: As Mad*Pow’s Behavior Change Design Director, can you tell us more about your background and responsibilities at Mad*Pow?
Dr. Bucher: I have a Ph.D. in organizational psychology from the University of Michigan, and have spent my professional career focused on applying behavior change principles to real-world interventions, especially around health. I started by researching patient and physician needs while working for an agency in Detroit, and then joined a startup spun out of the University of Michigan called HealthMedia that built B2B digital health coaching. HealthMedia was acquired by Johnson & Johnson while I was an employee, and I began working with internal J&J companies to find ways to integrate behavior change to their product and service offerings. I also spent time at CVS Health on their digital team for the specialty pharmacy working on improving medication access for chronically and severely ill patients.
At Mad*Pow, my role as the behavior change design director is to bring evidence-based behavior change science to the design process. This can take many forms. I work with clients and internal teams to help shape goals, define the research to understand the problem space, and plan for outcomes measurement. I work with our other design roles to define and build solutions. And I help clients think through implementation, user engagement, and ongoing outcomes monitoring. We can also help clients bring behavior change thinking directly into their organization through the workshops and trainings we offer.
Medgadget: How does understanding the psychology behind decision-making and motivation influence digital health design?
Dr. Bucher: If you approach digital health design from a behavior change perspective, you’ll start by clearly defining the desired goals — what do you want people to do? How will you know if it’s effective? Your other design decisions will cascade directly from the definition of your endpoints.
Once you understand the psychology of decision-making and motivation, your design process will relentlessly focus on taking the perspective of various users and stakeholders. It’s important to identify the barriers that might prevent someone from either staying engaged with your product, or actually making the health behavior changes in the real world. As you think through those barriers, you adjust your design to either avoid or overcome them.
And in doing that, you draw on empirically proven theories of behavior change. If someone’s barrier relates to their capabilities — having the information or knowledge or skills to accomplish a task — we can help with education and resources. If the barriers are related to motivation, we think about how to align behavior change with a person’s motivational needs — can we help them see the health behavior as an extension of their values? Can we help them feel a sense of growth as they work on change?
Medgadget: What are the most important aspects in design for motivating users to engage in a certain behavior or experience and/or adhere to it long term?
Dr. Bucher: I think of this as two separate problems: How do you design so that people participate in the first place, and then so that they choose to continue engaging over time? Depending on what you’re creating, that first participation problem might be solved external to the experience. For example, many of our clients might offer their users some kind of incentive to sign up for an app we’ve designed or enroll in an experience. Now the trick is to make them want to stay involved.
We often look to self-determination theory to help us with that. That’s a psychological theory of motivation that, at a high level, says that when people are getting their needs fulfilled by an experience they’re more likely to keep going with it. The specific needs targeted by the theory are autonomy, or meaningful choice; competence, or growth and learning; and relatedness, or being part of something bigger than yourself.
Medgadget: How do you incorporate those aspects into your design?
Dr. Bucher: We look for opportunities to support people’s psychological needs in the experience, whether through content, functionality, or process. For example, if we think about autonomy, how can we give a person meaningful choice at critical junctures in their experience? It’s nice to let people customize a dashboard or greeting, but that’s not a really meaningful choice. It is better to give people the chance to work through their health goals and their personal reasons for them, so that subsequent coaching feels supportive rather than imposed. We also know that people are more likely to feel ownership over a decision if they made it with full information, so we always advocate for giving people the tools to make an informed decision. With complicated choices like health plan selection or retirement savings vehicle, that means we work to present that information in an easy-to-understand and –use format.
Competence support relies on providing timely, actionable feedback that helps people reinforce success and recalibrate if progress isn’t what it should be. We look for opportunities to provide that at both granular and macro levels to help people adjust their in-the-moment behaviors while tracking to longer-term goals. It’s critical to make sure that feedback acknowledges success and not just opportunities for improvement, especially when someone may be struggling with change. Competence support is also an opportunity for tight collaboration between behavior change design and usability experts, since digital tools that are hard to use can quickly undercut people’s self-perceptions of ability.
Relatedness support could come from direct social support, but it can also come from feeling acknowledged and heard. Personalization can accomplish that if done well; it’s also another reason why feedback is important. Normative feedback can be especially helpful to foster a sense of connection: People love learning that others have similar struggles and experiences.
Throughout the entire design process, we look for opportunities to incorporate feedback from people who will eventually use the product. This helps us ensure that the motivational features we’re designing are engaging and support the efficacy of the app, tool, or experience. If timelines and budget don’t permit formal research, we’ll get creative about soliciting feedback from inside our own or the client organization to test designs.
Medgadget: Do these aspects of design apply to all age groups? Are seniors more reluctant or less likely to use digital health? If so, how can good design address that?
Dr. Bucher: Yes, the underlying motivational needs that drive engaging design apply to all age groups and segments. People may have individual differences in how much they want support in each of those psychological categories, but everyone needs at least some at all stages in the lifespan.
Technology is not the age differentiator people often assume it is. One thing I’ve consistently found in the research I’ve done is that seniors are not necessarily reluctant adopters of digital technology. Just like any other age group, seniors run the gamut from technophobes to technophiles. The balance is rapidly shifting toward more openness to technology among seniors as the Baby Boomer generation enters that demographic. Companies that avoid digital tools for their older users are missing an opportunity.
That said, it is important to consider the unique needs and challenges any user group brings, including seniors. You need to think about how your target users spend their days and how your tool will fit into that. It’s difficult to make any assumptions about what that looks like for today’s seniors, with so many people continuing to work well into their 70s or 80s. That’s one reason we try to do as much research as we can to understand target users in context instead of relying on our ideas of what they might want.
Medgadget: What are the biggest barriers or challenges to consumer adoption?
Dr. Bucher: One major barrier is the combination of a crowded marketplace and lack of a solid system to evaluate which options are really effective. If you look up how many health apps are hosted in iTunes, the number is staggering. For someone who’s looking for a tool to help them reach a goal, that’s overwhelming. And most people have no idea where to start in terms of sifting through those options to find promising ones, that are both effective in terms of achieving outcomes and engaging to use. One of my goals is to help health professionals and people making decisions from a health plan or employer perspective to do some of that expert evaluation and be a conduit to patients, members, or employees about what tools are worth their while to try.
Related to that, awareness may be low. With so many options, people may not even know about some of the higher quality interventions available. That means it’s critical when we’re designing a digital experience to also think about the offline touchpoints that might lead someone to engage. And it’s another reason to include health care professionals and other trusted figures in both the development and dissemination of a product, if that’s possible.
I also believe we have a consistent missed opportunity to transform participation — that initial download of an app or first few uses — into engagement, which is a more meaningful relationship over time. If you pay attention to the motivational dynamics within an app, they’re often geared toward either achieving business goals like data collection, or they mimic other popular apps without a lot of strategic thought as to what those features should be trying to achieve. If you start your design process by thinking about the user’s perspective — what the user wants to get out of the app and why the user might drop off — it helps to drive more strategic decisions about features to include. Can you make data collection more fun for the user, and offer ongoing feedback to support competence? Does a leaderboard really drive the outcomes you’re looking for, or did you just include it because “social challenges” are popular? The more we ask these types of questions of ourselves, the better our chances of designing something that flips a user from “participating” to “engaged.”
Link: Mad*Pow homepage…