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Behavioral therapy 'missing ingredient' for digital health success in diabetes

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February 22, 2019

Digital health tools designed to improve disease management for patients with diabetes often have little effect on long-term health outcomes, likely due to an insufficient emphasis on behavioral theory principles, according to a recent commentary published in the Journal of Diabetes Science and Technology.

David C. Klonoff

For those with diabetes, individual differences in psychological traits often influence the odds of success with digital health products like mobile apps or other smart technology, according to David C. Klonoff, MD, FACP, FRCPE, medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California. More personalized apps that account for such differences by incorporating health behavioral theories, he said, could potentially increase patient engagement and adherence to treatment.

“People talk about wanting to use digital health tools to give patients information or to motivate patients to follow instructions,” Klonoff told Endocrine Today. “Yet, there is a shortage of effective digital tools. Patients have no problem receiving information, but, in the end, often they either don’t act on it or they’re not motivated to change their behavior. Behavior is really the missing ingredient. Many mobile app tools do not include behavioral therapy, and that is why these tools often do not work.”

Unintentional vs. intentional adherence

The four purposes of digital health are to increase knowledge, promote healthy behavior, increase adherence to prescribed treatment and control an effector, Klonoff noted in his commentary. He cited four iterations of behavioral theory that might improve health outcomes in digital products if properly incorporated, including the Integrate, Design, Assess and Share (IDEAS) framework, the behavior change wheel, the Information-Motivation-Behavioral (IMB) skills model and gamification.

Before any behavior theory can be applied to a digital health product, designers must understand the difference between unintentional vs. intentional adherence, Klonoff said.

“Digital health tools are built on the assumption that people don’t intend to fail to follow therapy,” Klonoff said in an interview. “It’s the assumption that a person does not intend to not do what they’re supposed to do, but, rather, they simply forgot or did not understand what is asked of them. That is actually not true. Often, people don’t do what they’re supposed to do because they don’t want to. It’s intentional.”

The current digital health tools, Klonoff said, are designed as “reminders,” with the assumption that a “nudge” from a mobile app will change behaviors.

“Unfortunately, it is often more complicated than that, and the most effective tools should account for this intentional nonadherence,” Klonoff said. “That’s where behavioral theory can be effective, if it is used.”


Incorporating behavioral theory

The 10-phase IDEAS framework, Klonoff said, includes 15 “process motivators” that can promote adherence in a digital health tool, including challenges, providing choice/control, community, competence, competition, personalization, reframing and teamwork.

The behavior change wheel, a method for characterizing and linking behavior frameworks and behavior change interventions, has been used to assess the benefits of mobile app interventions designed to improve medication adherence for patients with hypertension and HIV with some success, Klonoff wrote, although little is known about how the theory would work when applied to diabetes apps.

The IMB model promotes increasing behavioral knowledge, personal motivation and social motivation; however, there is little research on the outcomes of mobile app interventions based on the theory. Similarly, gamification, a process that uses elements of game design to increase user engagement and interaction, has been shown to lead to short-term improved behavior, but data on long-term improved diabetes outcomes are lacking.

Additionally, digital health tools for diabetes intended for long-term engagement are most likely to succeed in the context of an empathetic physician-patient relationship in a patient-centered care model, Klonoff said.

“A proposed alternative to this relationship is real-time coaching via video or text by a remotely located professional, who represents the digital health product and may or may not be part of the traditional health care team, or else a virtual coach programmed by artificial intelligence,” Klonoff wrote. “Without a human component of a health care professional relating to a patient, however, long-term success from electronic digital tools will be difficult to achieve.” – by Regina Schaffer

For more information:

David C. Klonoff, MD, FACP, FRCPE, can be reached at the Diabetes Research Institute, Mills-Peninsula Medical Center, 100 S. San Mateo Drive, Room 5147, San Mateo, CA 94401; email:

Disclosure: Klonoff reports he is a consultant for Ascensia, EOFlow, Lifecare, Novo, Roche and Voluntis.

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