Why Are Wearable Health Technologies Failing?

The goal of most mobile health (mHealth) devices is simple: help users track and change their health behaviors. Many types of devices have been released, but most still fail to achieve this goal. Why?

Supported by endless media hype, the stock of mHealth apps and wearable devices continues to rise. Samsung, which expanded its line of wearables in early June, has joined Fitbit and Apple in the never-ending quest to improve fitness, reverse bad habits, and increase productivity (and sell more gadgets).

There’s a problem, though: more than half of mHealth apps in the iTunes store have been downloaded less than 500 times. And according to one survey, one-third of people who buy wearables stop using them within six months. In response, a new field of science is trying to understand the interface between human behavior and technology. This field, which I call the “Science of Social,” is maturing slowly, but it offers a lot of insight into the future of mHealth technologies.

The Science of Social

The three most important factors in behavior change are easy to summarize:

1. The power of social norms
2. The power of role models
3. The power of social support

Social norms strongly influence what we perceive as “normal” behavior. Do you silence your phone in the movie theater to avoid jeers? Have you ever listened to a genre of music you don’t like or rooted for a sports team that you don’t care about because your friends did? We value social support, so it’s common to adjust our behavior to what we think is expected.

Role models are responsible for popularizing behavior. New social norms spread when influencers adopt them first. For example, music trends in high school typically follow a top-down hierarchy. When I started to play bass guitar in 7th grade, I quickly discovered my favorite band—the Red Hot Chili Peppers—after hanging out with an 11th-grader role model.

Social support is key to sustaining behavior change. Friends and family fulfill key psychological needs, such as the needs to trust, fit in, and feel empowered. Successful offline programs like Weight Watchers and Alcoholics Anonymous include a strong element of community, so it’s not surprising that the top-downloaded apps are starting to include this feature.

These three simple principles determine the success of positive behavior change in the real world. Tech companies are catching onto this fact, but they’ve had trouble bringing all three elements together in one product.

How Tech Is Trying to Keep Users Engaged

One successful adjustment the mHealth market has made is using a reward system. The reward system can be complex, as in Zombies, Run!’s use of badges to unlock the next part of the story, or it can be simple, as in Fitbit’s growing flower that’s pegged to how many steps you take each day.

I’ve spent a lot of time advising companies on how they should incorporate reward systems into their products. The research shows that actionable goals (“I want to lose 15 pounds,” “I want to walk 15,000 steps today”) are key to making mHealth devices appealing to people in general, but especially to younger users. That’s why gamification and other interactive features that have a social element, like the personal coach found in Nike+ and other running apps, have helped increase the hype and sales of wearables. It turns out this age-old behavioral psychology technique—reward the desired behavior, or gamify it—is just as successful with us humans as it is with rats.

But gamification doesn’t always work, and there's still the problem of getting people to stay engaged. So, now what?

Using the Science of Social to Get People to Love Their Apps

At UCLA, we’re trying to improve the appeal of mHealth devices with a holistic model that includes all three elements of the Science of Social. This model, known as HOPE, targets one specific behavior to change.

Private community groups are the key to the HOPE intervention. People can support one another through group discussions, private messages, and “liking” posts and comments, just like Facebook or other social media sites. Interestingly, we’ve found that groups become actual communities after the intervention ends—they keep in touch, meet up with each other, and become part of each other’s lives.

In a nutshell, that’s the key to using the Science of Social to retain users: bridge the gap between online and offline worlds with social psychology. In order to do this, companies need to start being more aware of basic tenets of behavior change science, like the Science Of Social, and design around them. It’s encouraging to see health apps are going in this direction.

The (Social Media) Doctor Is In: Twitter Can Be Used to Monitor Health

“I hate Donald Trump!” “I’m exhausted and my boss doesn’t care,” “I'm jealous of my sister's new car.”

If this is what your tweets look like, then you might want to reconsider your words: research shows you may be at risk for heart disease. Most people don’t realize it, but the language they use in social media posts can be used to predict their well-being, like their risk for heart disease or other serious conditions. How can social media be used to monitor people’s health and overall well-being?

In one study, researchers evaluated 100 million tweets from 1,300 counties in the United States. The language in these tweets was analyzed and categorized as having either negative or positive sentiment. Then, the authors separated the words of each tweet into word clouds that reflected “risky” language (e.g., despise, hate, jealous, tired) or “protective” language (e.g., opportunity, strength, hope, great).

Using machine learning methods, the authors created algorithms that compared the sentiment of the tweets from each county to CDC data on causes of death. Their findings were dramatic: counties whose tweets expressed more negative emotion (e.g., tweets filled with words such as “hate”) had more heart disease–related deaths compared to counties that featured tweets with more protective language.

When looking further into the data, the methods worked very well at predicting death from hardening of the arteries (atherosclerosis), which is the leading cause of death in the United States. It’s interesting that the people who were tweeting were not the people whose deaths were measured. Instead, the overall tone of the tweets — which were from people too young to be suffering from heart problems — appeared “to have captured a snapshot of the psychology of the community at large.” The authors had therefore discovered a similar result to one that our own team found in an earlier study focusing on HIV.

The authors claim that their methods predicted death from heart disease more accurately than risk factors such as obesity, smoking, and diabetes. Moreover, the prediction accuracy remained strong even after they considered classic predictors of heart disease such as education as poverty. These claims might make you raise your eyebrows, but decades of research has shown that the words people use shows a lot about their psychology. In this case, the algorithms created by the researchers were able to predict personality traits. In fact, the authors claim the algorithms they developed predicted personality traits as well as or better than friends who filled out personality surveys about the participants!

So, how does this research impact your life? For one, an entirely new field of research, known as “digital epidemiology,” has sprung up around social media. Now that social media is widely used (65% of American adults visit social media sites regularly, and 90% of young adults use at least one service), doctors and researchers have an entirely new tool to predict communitywide well-being. Healthcare providers already monitor Google searches to forecast disease outbreaks (e.g., flu, malaria, STDs), which helps determine where resources should be allocated.

For individuals, the hope is that as more and more people use social media, health predictions will become even better. For example, future studies may ask patients to provide access to their social media accounts when they go to an emergency room or visit their primary care doctor. Language in postings and status updates could provide clues to the risk for depression, which is a major risk factor in the recurrence of many diseases. And existing studies have already helped identify post-partum depression among new mothers.

If trends are any indication, social media is going to become even more popular and integrated into tools to solve real-world problems. I’m hopeful that we’ll find ways to use social media to predict other leading causes of death in the near future, and that we’ll find an effective way to protect personal privacy at the same time.

Online Predators, and How Parents Should Deal with Them

“Oh my gosh, did you know that Nick Jonas was just caught with the Hollywood It Girl? Kate must be soooo mad!!!”

Danielle, a 13-year-old girl, often exchanges direct messages with her followers, so she isn’t surprised to see this question pop up on her phone. The message comes from a guy who identifies himself as David, an aspiring teen actor who just moved to town. They exchange a few more messages and he “seems nice,” so when David asks her to meet up the next day she agrees and gives him her cell number.

David starts texting her that night, sending a headshot, then a “muscle-shot,” and asks for a photo of her. David looks much older than expected, so Danielle gets weirded out and starts ignoring his texts. He gets persistent, and even aggressive, saying he’ll show her a lot more if she doesn’t respond. She responds with, “Stop texting me.”

Three days later, Danielle takes a call from an unknown number. It’s David. She immediately tells him to stop contacting her and hangs up. Scared to contact police or tell her parents for fear of getting in trouble, Danielle tries to distract herself by looking at Instagram photos.

Because of the Internet and social media, today’s kids are meeting more people than any previous generation. Unfortunately, like in the story above, they're not just meeting friends or teachers — they’re also meeting online predators who use a fake identity to try to lure teenagers, often into sexual acts.

What, then, can parents do to stop kids from meeting online predators?

In one study, 454 parents and their children participated in a research project on youth and Internet behaviors. The researchers assumed that most parents would underestimate how often children engage in risky online behavior, including unsafe interactions with strangers and exposure to sexual material. The goal of the study was to identify what contributed to this misconception.

Parents were asked, “How often has your child been approached online by a worrisome stranger?” For the children, the same question was phrased to distinguish what type of stranger they may have met: (1) an adult stranger that seemed interested in a sexual or romantic relationship, (2) someone who wanted to meet in real life, or (3) someone who was “just weird.” Parents were also asked how frequently they thought their child had been exposed to sexual content by accident or by intentionally seeking it out.

What did they find? One of the major findings was that parents who had poor communication with their kids were more likely to underestimate how safe their kids were online. Moreover, children who found it hard to talk with their parents were less likely to tell them about strangers they met online. These findings were similar to another study in which only half the children surveyed remembered being warned by their parents about talking online to strangers.

In their discussion, the authors describe the “third-person hypothesis," which proposes that people think that media messages are more harmful to others than themselves. Third-person perceptions in the study significantly increased the odds that parents would underestimate whether their child had been approached by a worrisome stranger. The authors speculate that parents who have a strong third-person orientation may assume that their child is smarter than other kids and, therefore, less at risk to be lured into a face-to-face meeting with a stranger.

So, how does this study provide answers about what parents can do to stop their kids from meeting online predators? For one, parents need to start communicating with children at a much younger age about online risks.

Children as young as 3 are starting to use digital devices, and estimates suggest that up to 90% or more of 12- to 18-year-old kids have access to the Internet. Society teaches that the “Birds and the Bees” talk should be the first sex talk that parents should have with their kids, but these days, parents should begin educating kids about risqué content and online predators well before that talk. This pre-“birds and bees” talk, which I call “The Birds and the Bees, Part 1,” should occur between ages 6 to 9. Yes, it’s unfortunate that kids need to be exposed to this conversation at such an early age, but it’s important to teach them about the risks they face. There’s no doubt this discussion adds another layer of complexity to the already-hard job of parenting, but the conversation doesn’t necessarily have to go into lurid detail. Instead, the idea is to open a line of dialogue and make kids aware that a parent is a safe adult and the primary person they should talk to if something online makes them feel uncomfortable or scared.

The findings from the study described above also have important implications for the increasing rates of cyberbullying happening among kids. And as you may imagine, parents underestimate their kids’ risk of being cyberbullied, too, but more about that in a future post.

The Health Habits of College Freshman: A Q&A with Sean Young, PhD

1. You’re conducting a research study to determine whether social media can be used to measure and predict health and academic performance among UCLA students 18 to 20 years old. Has this sort of study been done in the past with freshman students?    

To our knowledge, no study like this has ever been done. We’ve also given students wearable fitness and sleep tracking bands to evaluate their sleep and physical activity. A few researchers have published studies that monitored students with wearable trackers, but they did not include a social media component in the their research. We’re pretty excited about the innovation of this study and love coming up with creative new ideas for research.

2. One of your goals is to assess the relationship between writing about behaviors on social media platforms and activity/sleep patterns. What is the one area you expect the students to focus on the most in their social media posts? I would expect both schoolwork and personal relationships to be popular, but are you looking for the study to inspire other types of discussion?

This is exploratory. We definitely have some hypotheses of what students will be talking about and how it may affect their health and academic performance, but overall we’re looking at this study to give us some insights we can use in the future to build models to predict and improve student health and well-being. I think the topics they discuss is perhaps the less interesting question. As you mentioned, they’ll probably be most likely to talk about their schoolwork, job, friends, and hobbies. The more interesting question is how they’ll communicate about these things, what emotions they’ll express, whether we’ll be able to detect these emotions, and whether we can see and predict how they develop relationships over time purely by looking at their public social media data.

3. Since this study involves posting to social media sites, do you worry about the confidentiality of your participants? Also, you require “active postings” to social media sites. What exactly does that mean?

Because this is a pilot study, we need to gather a lot of data. In order to participate, we make sure students are Twitter users who are actively posting so that we can gather data from them. We’re not worried about confidentiality issues because people can change their Twitter settings. In most cases, people choose to have their Twitter handles public so that others can discover and follow them. That means that following someone on Twitter is like overhearing someone talking on the street. It’s all public information. If people don’t want to share something, they don’t have to, or they can go to a private area to share it. Our studies have found that people are growing increasingly comfortable with this concept.

4. With the release of the Apple Watch and other high-end fitness trackers, wristwatches have seen somewhat of a resurgence. However, some audiences still avoid wearables like the plague. Have any of your participants expressed discomfort or other issues with wearables during your studies?

I think it’s strong to say they’ve avoided wearables like the plague. I think they’ve avoided them like they avoided calculator watches, as I’ve compared them to in a previous post, because it’s still unclear whether they’re cool gadgets or whether they can impact people’s lives. The people who participate in our studies tend to be excited about our research and wearing the devices is a big reason why they want to participate. We’ve gotten a lot of athletes who signed up to participate, and many of them have reported back that the devices are helping them track their workouts. I think the next step or iteration is whether and how devices can help people who aren’t already doing things like exercising every day. In a previous post, I gave some examples of how wearables can become more effective at achieving this goal and leading to version 2.0.

5. How do you see your research helping improve the health habits of the first-year university students? And do you see any beneficial effects continuing later into life for these students?

Freshman students undergo a huge change in their lives when they start school. They move away from home, have to make new friends, are exposed to a lot of new experiences, and have to perform well academically compared to a smart group of peers. It can be a very stressful experience. It can lead to academic issues, mental health problems, or even suicide. Typically, it takes a while for university administrators to learn about students having these issues. Sometimes they don’t find out at all. The studies we’re conducting are aimed at developing tools that analyze data from technologies that students are already using in their daily lives, and use those data to predict and improve student health, well-being, and academic performance. We have the support of the university administration and if this approach shows promise, we hope to implement it more widely to help students better adjust to the transition from high school to college.

Join us: Innovative Use of Technology for HIV Prevention & Care - January 23, 2014

I am chairing a one-day UCLA conference on Thursday, January 24, 2014 on current and future ways to use technologies among communities at risk for HIV. The conference, sponsored by CHIPTS and the UCLA AIDS Institute, will focus on how social media and mobile technologies are being used to address community health disparities, especially focused on HIV and drug-related prevention and treatment.

A keynote speaker (TBA) will present on the current future ways that technologies are being integrated into community health. We'll then have panel discussions on researchers presenting their work on how social media and health can be used for community-level HIV prevention, followed by debates between developers and community activists/policy researchers on the privacy and ethical issues that need to be addressed when using these technologies.

The event will take place at the California Endowment at 1000 N. Alameda Street from 8:00 AM to 4:00 PM. Please email me if you're interested in requesting an invite or want more information.