How to design for health care engagement has become the most talked about design challenge in the United States. Across all industries – technology, government, advertising, medicine, etc. – resources are being poured into ways to better engage health care consumers.  The use of technology to reach consumers – the field of digital health – is one of the biggest market trends. According to a Rock Health Report, in 2013 $1.97 billion was invested in digital health startups, $120 million of which was invested in consumer engagement. Furthermore, digital health funding more than doubled between 2013 and 2014 according to this report.

How is this funding relected at the consumer level? Well, it may be too soon to know, but if the digital wearables space is any indication of what’s really happening, consumers seem interested in the adoption of technology, but they have a hard time integrating it into their daily life.  In fact, studies show that  while 1  in 10 consumers own a digital wearable device, 50% of those consumers no longer use it and 1/3 stopped within the first six months (source: ‘Inside Wearables’ white paper, Endeavour Partners).  Even though market projections say digital wearables will continue to boom – “more than 17 million wearable devices, including smart watches and _fitness bands, are expected to be sold in 2014 alone” and estimates are that “hardware makers would sell 23 million by 2015 and over 45 million by 2017” -these products are quickly collecting dust on the shelf.  Why?

Nobody has figured out how to crack the digital health behavioral engagement nut yet. We are getting better, but it’s still a wicked challenge – one that I have been working on my entire 20 years in health care.

I am a behavioral scientist dedicated to designing products, programs, and services for meaningful health care experiences.  More simply put: I am a behavior designer. Behavior design is the systematic, strategic, scientific approach to achieving behavioral outcomes. Rooted in psychology, behavior design methodologies help companies become clear on what problems they need to solve. My designs have failed and succeeded, and I’m getting better by learning more, experimenting more, and figuring it out.

Health care is social, psychological, and dynamic. So if we want to design for ongoing behavioral engagement, we must be better at catering to the consumers need to modify. We must design for “The Modify Factor”

Let’s use the practice of yoga to explore this issue. If you have ever taken a yoga class, you know some poses are harder than others. What determines whether or not a pose is “hard” for someone is a result of a combination of factors including experience, motivation, social norms, knowledge, mood, physical capacity, and energy.

When a pose is “too hard” any good yoga teacher will encourage a student to “modify” the pose. The lesson inmodify is to discover a slightly new and different way to move your body so it works best for you. Typically the decision to modify happens in real time, in that moment of the practice.Overall, however the goal is to empower the student to practice ways to stay engaged in the class. Without this ingredient of engagement, a student might have a negative experience\

What digital health products are not doing well yet is designing for the consumer’s need to modify. At some point, we all need to modify. Whether we are beginner or advanced, calm or stressed, motivated or lazy; sometimes we just need to modify.

Being able to modify in real time, because our teacher tells us to or because we decide we need to, is a critical factor in sustained engagement. And one theme that emerges in my consumer research over and over again is “I want my health care company to know me.”

So how can digital health products better design for the “modify” factor?

Designing around real human interaction or customer service is key for a health care engagement experience.

Some start-up digital health care companies  – like SessionsPokitDokSherpaaOmada HealthBetterHula(originally and Atelion Health, Inc. (originally CollaborRhythm) – are doing this. Sessions (recently acquired by MyFitnessPal) for instance, provides exercise health coaches with whom users can interact via text, e-mail, and phone when needed throughout a 12-week program. Sessions users who first sign up are linked with a health coach, who calls to conduct an in-depth starter session. During this initial phone experience, the coach asks a basic set of critical questions to assess the user. Once the program is underway, the coach regularly interacts with the user and vice versa. Sessions Founder Nick Crocker wrote, “people are adding a human layer on top of these [technology] applications, putting the power not just in the hands of the consumer, but in the hands of their network. This provides an incredible resource to doctors, trainers, and others who help people achieve their health goals.” I would argue that the technology is the layer on top of the human interaction, shifting some of the resource burden from the health provider to the consumer which is a good thing.


The main value of designing your technology around a human “authority” (a coach or some sort of figure who the consumer trusts) is that your solution will “meet the consumer where s/he is at” when they need to modify. Examples of companies providing contextual authority include Sherpaa and Livestrong. With Sherpaa, a consumer is able to navigate the health care system with the guidance of an expert when they need it. Informed decisions are made in real time, as the consumer needs to modify. As it says on their website, “That’s what we’re here for.” Livestrong offers patients “navigation services to provide the support you need as you face your cancer journey.” That happens through individual mentors who have deep experience with various aspects of cancer treatment.

Social Trust

If you cannot integrate a human authority into your solution, consider building in a social network. A social network solves for the human need because by design, it is person to person. You know there are other real people on the other end of the interaction.  If I knew that when I posted to Facebook, the other people reading were my trusted, valued health care providers, I’d engage to share health information because I would believe responses to my post would help me figure out how to modify my health.  This is one reason why patient portals, or Online Health Communities (OHCs), help users make more empowered decisions and stay engaged in health, because people who use OHCs trust the other members as authorities and have the chance to practice modifications.

The largest patient portal in the world is PatientsLikeMe (PLM). Approximately 230,000 patients engage with PLM. According to co-founder Jamie Heywood, over 2,000 health conditions are mentioned; 4,000 posts; and 16 million data points are logged per year. PLM published research in the Journal of Epilepsy that shows how PLM engagement increased adherence tied to outcomes by 19% among patients with epilepsy. “Prior to using the site, a third of respondents did not know anyone else with epilepsy with whom they could talk; of these, 63% now had at least one other patient with whom they could connect. Perceived benefits include: finding another patient experiencing the same symptoms, gaining a better understanding of seizures, and learning more about symptoms and treatments”  said Heywood. Users of PLM trust other users. And now, health insurance companies like Aetna are promoting PLM on their homepages.

What this is all about – and what is needed when you want to modify – is trust. Trust that your modification will make it better. So if you are going to build a social network into your product, make sure it allows for trustworthy interactions.

Build digital health technology that is an extension of what is already working in real life.  I recently interviewed a cancer patient who was first diagnosed in 2007 and then again in 2012, and he said “The conversation where I received the most support during my treatment was right before my first stem cell transplant – I got a call from a friend who had been through it, and she told me what to expect. She talked me through the process and made herself available to me when I had questions. It helped with my decisions. It was so comforting.” He might have been able to have a similar experience with Better – because Better provides on demand assistance. Consumers can interact with their own Personal Health Assistants to talk about the information and any discuss questions or concerns they may have, on the spot.

Digital wearables need to improve the way they serve consumers. Give consumers more than one reason to pay attention to the numbers flashing across the fancy band. During a recent interview with a Fitbit user, she said “I actually didn’t think I’d still be using my Fitbit, but my whole family decided to embark on a family fitness challenge….my uncles and cousins, even my Mom…we are all competing against each other to see who can walk the furthest. It gives me a reason to check in regularly with people I care about, and I like that.”

To clarify, designing for the modify factor is not about getting consumers to your product or program for the first time – it is not about persuading a first time yoga student to enter the yoga studio. The modify factor is about designing the engagement experience once the students is there. Keeping your consumer engaged once they have arrived.

What you can do:

  • Conduct user research so you are clear about your target customer’s needs and values. This will not only allow you to empathize and capture consumer behaviors, but also allow you to know what is needed to build trust. Health is social; we want other people to validate our decisions.
  • Prototype often so you can test how well your solution is meeting the needs of your consumers. Too few health care companies do this. Health happens in real time – we need what we need when we need it. An ongoing prototyping plan enables you to build agility into your solution.
  • Design for behaviors, not technology. This is one the biggest mistakes I see in corporate healthcare: companies choosing to let product requirement didcate the consumer experience design.
  • Define clearly what engagement means to your business and integrate a way to measure that engagement over time so you can regularly pinpoint “the modify factor”.


Dr. Steph Habif is a California based behavioral scientist with 10+ years of experience leading corporate and start-up health care teams through human-centered design processes to achieve behavior change. She has led projects for companies such as Whole Foods Market, Aetna Inc, and Hot Studio by conducting in-depth user research, teaching behavior design workshops, and coordinating events that bring industries together to improve health care systems. Steph currently teaches several classes at Stanford University’s Hasso Plattner Institute of Design, and she is an affiliate of the Stanford Persuasive Tech Lab. Steph has a doctorate in health behavior science from Columbia University, a masters in counseling psychology from Springfield College, and a bachelors in psychology & english literature from Washington University in St. Louis. You can learn more about her at

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