'Not everyone has health goals at the top of their list'

Doctors can repair a lot, but preventing or delaying illness is better. This often requires lifestyle change and that turns out to be difficult. Dr. Valentijn Visch (TU Delft, Industrial Design) and dr. Sandra van Dijk (Leiden University, Social Sciences) are doing research on how to help people with behavioral change and what role e-health can play in this.

This double interview is one of seven double interviews with fourteen scientists of Zuid-Holland in the white paper "Towards a healthy society for all”. Sender is Healthy Society, a collaboration of Leiden-Delft-Erasmus Universities and Medical Delta. The white paper can be downloaded here.

People often find it difficult to start living healthier lives. Even if they know they have an increased risk of serious diseases. Why is that anyway?

Valentijn Visch, who researches Design for health motivation at Delft University of Technology and is one of the Scientific Leaders of the scientific program Medical Delta eHealth & self-management for a healthy society: 'I regularly see people for whom everyday life is already an enormous 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 neighborhoods, the motivation for behavioral change is therefore often low’.

Sandra van Dijk, health psychologist at Leiden University and Scientific Coordinator of Healthy Society: 'Stress and mental complaints play a big role in this. We know that about 30 percent of people with chronic conditions suffer from anxiety and depression symptoms, and these make it difficult to live healthier lives. So it's important to look broader than health alone. If someone has mold on the walls or is financially strapped, it probably doesn't make much sense to unilaterally start talking about lifestyle adjustments. After all, we also know that stress makes people more focused on short-term rewards.'

And healthy behavior is never rewarding in the short term?

Van Dijk: 'That it can give you more years of life in good health is something you generally 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 of their list. For example, in a lifestyle intervention we created with migrants, we found that it was important for them to practice relaxation in all group meetings.'

We added a 3D environment to the training in the form of a beautiful garden

Visch: 'Well, being more relaxed and therefore sleeping better, for example, is of course also healthy and immediately rewarding. Moreover, it gives people the feeling that they have more control over their lives. That increases their so-called self-efficacy. Another way to make working on health rewarding in the short term is to give gifts. We are both involved in research on a lifestyle intervention for people undergoing cardiac rehabilitation. In it, participants can earn points through healthy behaviors that save them for presents. Just like assigning levels, this is an element that is often used in games.'

Is it wise to entice people into healthy behavior 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 behaviors. It is then important to combine that with other behavior change techniques, to ensure that people also become intrinsically motivated to maintain that behavior in the longer term.

What else can game elements contribute to e-health programs?

Visch: 'Above all, they can make those programs more fun. For example, 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 that help them. This gives them a nice, safe "garden" in which to roam at difficult times.

More and more online treatment options are emerging. Online cognitive behavioral therapy, for example, has been proven effective. But what about accessibility? Can everyone use it?

Van Dijk: 'That is really a point of concern. As many as one in five Dutch people have difficulty with computers, the Internet and apps. A few years ago we developed an online intervention that was secured with two-factor authentication and that turned out to be impossible for many participants!'

Visch: 'Moreover, the information offered online is really too difficult for some people. In face-to-face contacts, doctors or therapists can adjust the communication directly to who they have in front of them, but e-health can't 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 healthcare offerings.'

Co-creation is more than just carefully asking the wishes of your target group

Van Dijk: 'Of course, a lot is already being done to make tools a little 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 that, we can ensure that e-health doesn't widen the health gap too much.'

And if you want e-health to actively reduce the health gap?

Van Dijk: "Then more needs to be done. Key words then are co-creation, integrated approach and personalization. Co-creation means that you not only carefully ask the target group about their wishes, but that you actively involve people in the development of an intervention from the beginning. 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. Because as we said before: in order to make a start with healthy behavior, sometimes other problems have to be solved first.'

'By personalization, 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 multiple areas of life where personalization can work well. I think that with algorithms we will be able to predict much better in the future which smart combination of support will help someone best. That really doesn't 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.'

By Anne Pek

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 behavioral 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 the Faculty of Industrial Design Engineering at TU Delft, specializing in Design for Health Motivation. He established a research line on persuasive game design within the eHealth Lab. Since 2017 he is one of the scientific leaders of the Medical Delta program eHealth & Selfmanagement and recently also of the Convergence theme Technology-supported Transitions in Healthcare.