Digital health behavior change applications are abundant, but low engagement statistics suggest they often don’t meaningfully respond to consumers’ motivations. It's easy for designers to see users’ long-term health needs while staying blind to the short-term motivations that often drive behavior.
Beyond smart digital design, behavior change products need propositions and marketing strategies that appeal to this short-termism if we want to see engagement.
In Field of Dreams, Kevin Costner gave us the often-repeated adage: “If you build it, [they] will come.” But product designers living by this mantra might fall into trouble.
In behavioral science we hear about the “overconfidence bias” – the tendency to underestimate our chances of failure. This is one reason why there are more entrepreneurs entering the market than there are successful businesses, and more “better than average drivers” than is statistically plausible.
Is this a problem that some health behavior change app designers face? The statistics show an abundance of options available to consumers. In 2020, over 400,000 health apps are available in the app stores. Clearly, product designers are seeing the potential of digital solutions for health challenges.
But user engagement remains problematic. Most health apps have been downloaded less than 10,000 times, according to usage data, and research suggests that typical medical and fitness apps have low 90-day retention rates. Given that when people do engage the health outcomes are positive, these estimates make frustrating reading.
This begs the question: How much do we really understand about users’ motivations to use digital products for improving health?
We can think of users, and ourselves, as having two conflicting sets of motivations. One set includes long-term, virtuous, and logically appealing goals – the health maximizing “hero” motivations like staying healthy to avoid disease and live fulfilling lives. Another set includes short-term, hedonistic, emotional, and often effort-saving drivers of behavior – the “Homer Simpson” motivations like eating cake for the immediate pleasure. We are all heroes and Homers.
Our long-term health needs don’t always drive our behavior. This is probably self-evident. Despite knowing the risks, we all fail to do things that are good for us, or actively do things that are bad for us. Eating unhealthy food, drinking, driving too fast, avoiding exercise, and even avoiding seeing doctors are all problems that most people are aware of but don’t always act on.
In the 1970s, psychologists conducted a series of famous studies in which children were left in a room with a plate of marshmallows and were told if they left them alone, they’d be given more when the experimenter came back. Predictably, many of the children didn’t hold out.
This, and many studies since, show that we’re disproportionately swayed by the temptation of short-term rewards at the expense of our future goals. If you asked me whether I would choose a donut or salad as a snack next Friday, I’d find it easy to claim I’d choose the salad. If you offered me the choice right now, the donut would be gone in seconds; the promise of immediate pleasure from eating outweighs my long-term goals to lose weight and stay healthy.
This is problematic both for promoting healthy behavior and for understanding health product users. We are very good at believing our hero motivations and failing to acknowledge the Homer-esque short-termism that often drives our behavior. Consequently, even when users are brought into the design process, it’s easy to believe that products are designed for their needs, while actually being designed for unrealistic health maximizing versions that we create.
When it comes to designing for long-term goals, such as staying healthy to avoid disease, designers must acknowledge that seemingly illogical short-term, emotional, and social motivations can be more important. We are all heroes and Homers and both versions of ourselves are important. But it seems easier for designers to see users’ hero motivations and forget about the Homers.
Product designers face two user engagement problems: creating propositions to attract users in the first place and subsequently sustaining their engagement.
It is seductive to think of this as a digital design challenge. User experience (UX) is a fashionable discipline and creating slick, feature-rich applications is a tangible and demonstrable beacon of product development progress. Incorporating behavioral science into design can be fruitful for creating sustained engagement. But without a proposition that appeals to consumers and focuses their goals, even the smartest design could be accused of having style without substance. The proposition problem is the bigger challenge and perhaps where the greatest investment is needed.
One product type from the insurance industry that has solved this problem is telematics car insurance for young drivers. Telematics products use black boxes installed in customers’ cars to monitor driving styles, allowing the insurer to select and manage risks. In exchange for monitoring, customers receive substantially reduced premiums compared to non-telematics policies, as well as other financial benefits depending on their driving performance.
There are parallels between health behavior change and telematics programs. Both aim to change risky behavior, often using digital applications. Both have implicit potential for significant long-term benefits: Telematics empowers customers to monitor their own driving and reduce their risk of crashing, while health behavior change products enable consumers to manage their long-term health risks. The implicit long-term benefits of both product types rely on customers engaging hero motivations, but telematics has solved the problem of Homer-esque tendencies by offering a compelling proposition that appeals to short-term motivations.
Digital health behavior change needs to find its own way of moving beyond solving long-term hero-level goals to find propositions that work for customers’ short-term needs. While the context is very different from motor to life insurance, there are examples of successful incentivization approaches in health. Weight Watchers rewards customers’ behavior with “SmartPoints”, substituting the long-term goal of losing weight for immediate rewards with exchangeable value. Similarly, Vitality offers customers rewards including an Apple Watch that they receive for free if they continually meet exercise goals, thus appealing to both short-termism and the behavioral principle that standing to lose something is more powerful than standing to gain.
However, financial incentives might not always be feasible. The extent of premium reduction on a life insurance policy might not be substantial enough to meaningfully motivate engagement – not a problem for telematics programs, considering the high premiums for young drivers. Financial incentives might also disproportionately benefit the already motivated – a smart strategy for attracting good risks but less so for changing the behavior of existing risky customers.
But marketing can appeal to other non-financial short-term goals. In 2019 a large health messaging study found that consumers were more likely to respond to an alcohol intake intervention when the communications emphasized the effects on their physical appearance rather than the health risks of drinking. The study also found that those who saw the health message were more likely to seek information following the initial intervention. Perhaps, therefore, digital health behavior change propositions need marketing strategies that emphasize immediate and socially relevant needs alongside health messages to stimulate and maintain engagement.
As this study showed, digital health behavior change may benefit from positioning that solves a social identity problem for consumers, rather than a health problem alone. Identity is a fluid construct that we create and maintain and is expressed differently in different contexts. We work to understand and create the people we are, who we want to be, and who we want to present to others. Perhaps digital health propositions can demonstrate how they can help consumers be the people they see themselves as, or their social group values. Marketers can ask the question: How do the outcomes of using digital health resonate with society’s ideas of success? These identity motivations might be more likely to resonate than the ultimate benefits of avoiding disease.
There is no silver bullet. But it’s clear that product designers should not underestimate the role of creating compelling propositions and communication strategies. Thoughtful UX design is certainly important for retaining users, but without a proposition that appeals to the short-term motivations that really resonate, even the smartest designs will gather dust.
We certainly should not assume that digitization alone will turn consumers into the health-maximizing hero beings we – and sometimes they – think we should be. Behavioral science tells us that we need to cater for, or create, the needs that often really motivate behavior – the immediate, emotional, social, and rewarding Homer-isms – if we want to see engagement. This is not a case of if we built it, they will come.
