Why are we interested in activation?
Patient activation describes the knowledge, skills and confidence a person has in managing their own health and health care. Patient activation and engagement is widely recognised as being a key determinant for health outcomes, and yet, in the context of health and care, few organisations have in-house expertise in putting empowering methodologies into action (Greene and Hibbard, 2011). I recently wrote a blog about how, in the context of the NHS.UK alpha, we were measuring pre-existing levels of activation in those participating in our user research. Getting great behavioural insights baked into our methodology is our ultimate objective, and our first step towards that goal has been considering patient’s existing levels of health confidence.
In digital health and care, it is crucial that we don’t get lazy, and confuse convenience with the nebulous and messy concept of activation. More specifically, making things digital often makes them much more convenient—it doesn’t necessarily empower or activate people towards better health. In other words, making things digital may just make them more convenient and accessible for those who are already engaged in their health and care. It may not have any impact on the excluded, or non-engaged.
Activation, great design or both?
It is critically important to differentiate when we are speaking about activating people who are dis-engaged in health and care services generally, and when we are making services easier to access using digital as a tool for engagement. The former is a complex approach that should consider the “bio-psycho-social determinants of health,” aka the holistic person-centred view. The latter is where great design approaches can delight users, drive engagement and build a long term relationship with your digital service…assuming that users were activated enough to access your shiny digital tool in the first place.
Indeed, this very challenge came up in a user research session recently. Here, my objective was to present a scenario that would motivate the user to click a link we had sent them by text. However, the user steadfastly refused to click the link stating that, if we were asking them to behave authentically, their authentic response was to not use the digital service offered. In the same way I throw away the junk mail that is delivered to my door each day, this user viewed our text invite to a digital platform as no more than digital junk mail.
What do we know?
The anecdote above highlights lesson 1: some people just aren’t interested. Not to be confused with digital exclusion this is about people willing and able, but not interested in digital for health and care services. These people may love social media, and online shopping, but just because they are capable of using digital things, doesn’t mean that they will use them for health and care self-management. Why? Well, I don’t have an empirical answer, but I would guess it is because Instagram is more fun than something health-enhancing, like online calorie counting.
Here comes lesson 2 (part A): in order to drive adoption, the digital offer has to be better than the non-digital alternative. In the case of something like calorie counting, a digital diet diary would probably be most appealing to someone who already calorie counts, but uses a less convenient thing like a paper notebook. Digital functionalities like barcode scanning add tremendous value to the already engaged, but will probably not be a sufficient draw to those not already actively monitoring their diet. In other words, for the majority of people, nifty digital innovations like barcode scanning for calorie counting won’t cause the masses to suddenly start keeping a food diary.
However, this then brings me to lesson 2 (part B): building an awesome digital tool that resonates with the real needs of patients can drive engagement. It may sound like I have just contradicted myself. However, the devil is in the detail on this one, so here is the take away: making something shiny and digital won’t necessarily convert people to using it in the absence of wider integration into their existing health and care journeys. In other words, pretty digital things won’t lead to health improvements in the absence of broader end-to-end service redesign. However, some health and care transactions are really cumbersome, and making services like booking easier and faster can help us build a better relationship with our users, fostering interest in other digital health and care transactions.
This brings me to lesson 3: if we can support people towards something new and digital, they may be converts, with the right level of support. Here is where we need to bridge the online tool into the offline user journey. This is about great end-to-end service design. In the case of the user I described above, when we (somewhat artificially) showed them our planner prototype, they instantly loved it. But in order to persuade this user to try the tool, I had to draw upon their existing relationships with service providers. Here, the only way the user would try the tool was when I asked them to imagine that it had been highly recommended by their favourite clinical team. What does this tell us? We need to embed digital offers meaningfully within the wider experience of care of the user. If a gatekeeper presents a new digital tool in the right context, and at the right time, people who might ignore your product may be persuaded otherwise. This applies both to driving initial uptake, but also sustained usage.
The health and care special snowflake
Things like “present bias” and “hyperbolic discounting” make it hard for humans to make healthy choices. This applies to most public health challenges, including digital health. Unlike many online transactions such as paying a bill, pro-actively engaging with health and care services is not generally an obligation. If you don’t pay a bill, a collector might eventually show up at your doorstep. If you don’t take care of your health, you probably won’t be chased up by anyone. This poses a real challenge in the adoption and usage of digital health products.
We can promote great tools, such as online mental health services, but unless those tools are being promoted to the user by someone in their treatment pathway, or they (the user) goes looking for it, they probably won’t find it.
The evidence tells us that patients and carers are most likely to use online tools for health when they are recommended to do so by their clinicians. Therefore, in order to make new digital services work, it is crucial for clinicians, and frontline health and care professionals to like and recommend digital tools to their patients. Additionally, as Simon and Ninjeri recently wrote, in order to add value to patients, carers and professionals, digital solutions must integrate with frontline workflows.
Engagement as a means to activation
Engaging with clinical stakeholders will need to be a key part of our work on the NHS.UK alpha. If we are successful in building tools that meaningfully support people working in frontline roles to do their jobs, then it is more likely that practitioners will promote digital tools to their service users. However, it is crucial that—aside from being clinically safe—that the digital tools we offer reflect the needs of the end-users.
Dr. James Woollard, Senior Clinical Fellow in Mental Health at NHS England, does an outstanding job of explaining this very issue:
“Inauthentic end-user design creates halls of mirrors and fallacies that serve no one and cost a lot. I use the word authentic, because there is a danger that we don’t engage with this in a genuine way with the end user, whether that is a professional or person using services.’’
Here, we get into to the space of consultation versus co-production. Co-production builds on consultation and “refers to active input by the people who use services, as well as – or instead of – those who have traditionally provided them.”
One of the best pieces of work to understand co-production was made by the good people over at Nesta. “The depth of co-production,” they argue, “can fall along a scale from fairly tokenistic user-involvement all the way through to a complete transformation of power relationships within services.”
Activation for service transformation
Great service transformation isn’t about digital services. It is fundamentally about looking at an end-to-end experience, and reworking the parts that don’t work, drawing upon digital as one tool to fix the problem. In this way, making digital services better isn’t simply about building sleeker websites. It also involves authentic and genuine engagement with patients, carers and clinicians to collectively solve problems, and implement the solutions.
While seemingly abstract, one first step towards building meaningful engagement and activation with a digital service is to first start with how activated people already are. Get your baseline. Using tools such as the Patient Activation Measure or Health Confidence Score is an excellent way to figure out where you are starting from, and help you plan how you can build or transform awesome digital things that work for real people, in the real world.