Doctors can fix a lot, but preventing or delaying disease is better. This often requires lifestyle changes, which turns out to be difficult. Valentijn Visch and Sandra van Dijk are researching how to help people change their behaviour and what role e-health can play in this.
People often find it difficult to start living healthier. Even when they know they have an increased risk of serious diseases. Why is that anyway?
Valentijn Visch, who researches Design for health motivation at TU Delft: 'I regularly see people for whom everyday life is already a huge struggle. They have very little energy left to worry about possible future health problems. It just doesn't tell them that they have a better chance of a healthy old age if they stop smoking now. Especially in vulnerable neighbourhoods, motivation for behavioural change is therefore often low.'
Sandra van Dijk, health psychologist at Leiden University: 'Stress and mental complaints play a big role in this. We know that about 30 per cent of people with chronic conditions suffer from anxiety and depression symptoms, and these make it difficult to live healthier lives. So it is important to look wider than health alone. If someone has mould on the walls or is financially trapped, it probably doesn't make much sense to start unilaterally talking about lifestyle adjustments. After all, we also know that stress makes people more focused on short-term rewards.'
And healthy behaviour is never rewarding in the short term?
Van Dijk: 'The fact that it can give you more years of life in good health is something you usually only experience in the longer term. Moreover, physical health is only one element of well-being. We perhaps assume a little too easily that everyone has health goals at the top. In a lifestyle intervention we made with migrants, for instance, it turned out that it was important for them to practise relaxation in all group meetings.'
Visch: 'Well being more relaxed and therefore sleeping better, for instance, is of course also healthy, as well as immediately rewarding. Moreover, it makes people feel more in control of their lives. That increases their so-called self-efficacy. Another way to make working on health rewarding in the short term is to give presents. We are both involved in research on a lifestyle intervention for people undergoing cardiac rehabilitation. In it, participants can earn points through healthy behaviour which they use to save for presents. Just like assigning levels, that is an element that is also often used in games'.
Is it wise to entice people into healthy behaviour with presents? Then it doesn't really come from them, does it?
Van Dijk: 'Indeed, I used to be taught that you had to be careful with rewards; they would affect someone's intrinsic motivation. But in the short term, extrinsic motivation can help people develop new habitual behaviour. It is then important to combine that with other behaviour change techniques, though, to ensure that people also become intrinsically motivated to maintain that behaviour in the longer term.'
What else can game elements contribute to e-health programmes?
Visch: "Above all, they can make those programmes more fun. For instance, we recently gamified an existing online therapy for people with anxiety disorders. In that training, people had to write about things where they felt safe and comfortable. They could then look up those notes as soon as they felt an anxiety attack coming on, with the idea that the anxiety attack would then become less severe. We have added a 3D environment to this training in the form of a beautiful garden in which participants can hide their notes. They can also upload pictures or music into it that help them. This gives them a nice, safe "garden" in which they can wander at difficult moments.'
More and more online treatment options are emerging. Online cognitive behavioural therapy, for instance, has been proven effective. But what about accessibility? Can everyone use it?
Van Dijk: 'That is a real concern. As many as one in five Dutch people have difficulty with computers, internet and apps. A few years ago, we developed an online intervention that was secured with two-factor authentication and for many participants that turned out to be impossible!'
Visch: 'Moreover, the information offered online is really too difficult for some people. In face-to-face contacts, doctors or therapists can adapt the communication directly to who they have in front of them, but e-health cannot do that at the moment.'
How does that affect the health gap?
Visch: 'Because of such things, vulnerable people can drop out. So the risk is that they miss out on more and more of the care on offer.'
Van Dijk: 'Of course, a lot is already being done to make tools a bit more accessible for people with fewer skills. Think of simple things like replacing pieces of text with a video. If we pay more attention to this, we can ensure that e-health does not widen the health gap too much.'
And if you want e-health to actively reduce the health gap?
Van Dijk: 'Then more needs to happen. Key words then are co-creation, integrated approach and personalisation. Co-creation means that you not only ask the target group carefully about their wishes, but that you actively involve people in developing an intervention from the start. That way, you can be sure that together you are creating something that the target group really needs. By integral approach, I mean that you have to have an eye for the whole context, including the social one. Because as we said before: in order to make a start with healthy behaviour, sometimes other problems have to be solved first.'
'By personalisation, I mean that you can make people an offer of support that is completely tailored to their situation. Especially with vulnerable people, there is often an accumulation of problems in several areas of life where customisation can work well. I think that in the future, algorithms will allow us to predict much better which smart combination of support will help someone best. That really does not necessarily have to be an e-health intervention. We shouldn't want to send everyone out the door with an app. Face-to-face contacts will always remain important, especially for people who are vulnerable.'
Sandra van Dijk (1972) is associate professor in the Department of Health Psychology at Leiden University. Her research mainly focuses on the development and evaluation of behavioural interventions for diverse target groups, including people with chronic illnesses. Since January 2022, she has been scientific coordinator Healthy Society for LDE Universities and Medical Delta.
Valentijn Visch (1971) is associate professor at TU Delft's Faculty of Industrial Design Engineering, specialising in Design for Health Motivation. He set up a research line on persuasive game design within the eHealth Lab. Since 2017, he has been one of the scientific leaders of the Medical Delta programme eHealth & Selfmanagement and recently also of the Convergence theme Technology-supported Transitions in Healthcare.
White Paper Healthy Society
This is a publication from the white paper 'Healthy Society: towards a healthy society', published by Leiden-Delft-Erasmus Universities and Medical Delta.
Text: Anne Pek; Translation via Deepl
