'Within conversations you discover the problem behind the problem'

You have young people on e-bikes or with parents as drivers, but you also have young people who cannot walk the streets safely. Design scientist Maaike Kleinsmann (TU Delft) and communication scientist Moniek Buijzen (Erasmus University Rotterdam) talk about solutions for the health of children and young people. 'It shouldn't feel like just another system.'

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.

What does a child in our time desperately need to become a healthy adult?

Maaike Kleinsmann, professor of Design for Digital Transformation, Medical Delta professor and one of the scientific leaders of the Healthy Society in Medical Delta scientific program: lifestyle & prevention: 'Knowledge of what is healthy and what is not is not as obvious as it seems. I struggle with it myself in the supermarket. Sometimes something has more sugar in it than I thought, even though the packaging has a healthy appearance. If you want to eat healthier, you have apps where you have to enter everything you eat. Quite a hassle, you don't keep that up. I also find the health labels on products complicated. Today's designers are looking at how they can support users in making healthy choices. For example with apps, but perhaps also with smart shopping baskets that provide information as soon as you pack a product. It should not feel like another system, but be present in the background. It should not be patronizing and should assume the will of the user.'

Moniek Buijzen, Professor of Communication and Behavioral Change: 'Digital resilience is important, even when it comes to healthy eating and exercise. Young people spend so much time in a digital environment, this has really become part of healthy living. They need to be aware of steering algorithms, cookies and surreptitious advertising. Messages young people pick up online have an effect - on top of the influence of classmates. In our Movez-team, we are investigating, among other things, how influential classmates or neighbors can encourage healthy behavior and also how this can be done through social media. For the latter, we use algorithms, for example, to track who is "talking" to whom on social media.'

Growing up healthy involves so much; a lot goes wrong. How do you tackle that with science?

Kleinsmann: 'In the research initiative Healthy Start, we are trying to break through the unequal starting position of children and young adults in Rotterdam in six important aspects. These are the first thousand days of life, care pathways for young patients, exercise in chronically ill children, mental health, crime & addiction and youth participation.'

'I'm leading a project to get chronically ill children with congenital heart defects, for example, to exercise more. Their parents are often very careful with them and they ask the gym teacher to be the same. As a result, they sometimes develop new heart problems from too little exercise as early as age 40. Later in life, they then experience the adverse consequences of lack of exercise in a very unpleasant way. We are working on a system with three components. First, a chatbot on parents' phones that can help and reassure them. Second, a fitness tracker that monitors whether children are moving safely and enough, supplemented by game elements that encourage movement. Finally, a dashboard for the doctor to look longitudinally at how the child is doing.

Talking to these young people showed that they had completely different things on their minds. (...) So we have to work on that before we can encourage them to eat oranges.Buijzen: "I am involved in youth participation within Healthy Start. For example, we help young people in Rotterdam neighborhoods improve their own living environment, health and well-being. They work together with researchers, policy makers, youth workers and urban designers to create a better environment. Also their digital environment, where they help each other on their favorite social media to be more resilient. With encouraging hashtags like #beyourownjoy. This should lead to a healthier lifestyle and more social cohesion. That promotes health and well-being and reduces health inequalities.'

It seems cumbersome, improving health with such a complicated project. Why not just promote healthy behavior?

Buijzen: 'We discovered in 2021 that that doesn't work, during the theater project #Influence in Rotterdam Zuid. Talking to these young people showed that they had completely different things on their minds. There had just been a shooting in Feijenoord; they didn't feel safe on the streets. They didn't feel comfortable online either. Their self-image was undermined by all those beautiful Instagram photos. So we have to work on that before we can encourage them to eat oranges.'

Kleinsmann: 'Even in our remote patient management projects, there are many difficulties to overcome before you can start working on health. Technically, but also with the cooperation between healthcare institutions and families. Everyone has to be familiar with the technology and trust it. In families they have a lot on their minds, and we are also dealing with less literate people. Medicine and nursing schools need to include e-health in their curriculum, which is also happening more and more.'

Can your solutions stand up to the huge marketing budgets of the food industry, for example?

Kleinsmann: 'Yes, it is difficult. A big annoyance for me are sports canteens where I go with my daughter.' Buijzen: 'A brand like Red Bull is prominent in sports on purpose. Once a child associates sports with Red Bull, such an association can last a lifetime.'

In our old projects with boring questionnaires, we always had great difficulty finding schools that wanted to participate. Not anymore: we work with a mix of learning and playing.Buijzen: 'I have long since passed the stage of despair. Like a turtle, I just keep on stepping. Fortunately, I do notice that standards have changed in the past twenty years, even in the industry. Although I have become more skeptical about solutions along with industry. The percentage of overweight people is still growing, but the growth is starting to level off. It is a wicked challenge, all stakeholders at all levels are needed. Also more laws and regulations at the macro level, think sugar tax and restrictions on advertising. Just as rules have come in for the amount of salt in bread.'

How can you make a difference now, using interventions to put a positive spin on health?

Buijzen: 'We found that you have to involve your target group from the beginning of the idea. What are their values and needs? What do they find interesting and important? In our desire to be effective and save money, values like autonomy and privacy often fall by the wayside. In our old projects with boring questionnaires, we always had great difficulty finding schools that wanted to participate. Not anymore: we work with a mix of learning and playing.'

'Young people already use social media, as well as movement apps like Strava and Garmin. For convenience, fun and social contacts. We are now connecting to that. They play with their own avatar in our app, give it a new outfit every day. In conversation with young people, they came up with the name of our Movez-lab. We also learn from them, that equality works.

Kleinsmann: "Co-creation also works best with us. In conversation you find out what the problem behind the problem is. The reason that sports canteens offer little fresh food is that it does not have a long shelf life and a lot has to be thrown away if it is not bought. Then you can come up with a solution for that, for example. We sit at the table with a whole network of actors: patients, doctors, nurses, management teams. Technology itself is also an actor. We as designers can only come up with solutions that really work from that collaboration.'

By Rianne Lindhout

Moniek Buijzen (1973) is Professor of Communication and Behavioral Change at Erasmus University Rotterdam. She is also Professor of Strategic and Persuasive Communication at Radboud University. She works on positive behavior change, where, for example, healthy young people from disadvantaged neighborhoods are an inspiration to others.

Maaike Kleinsmann (1976) is professor of Design for Digital Transformation at TU Delft. She is also a board member of the National eHealth Living Lab (NeLL) and one of the leaders of the convergence program Healthy Start. She develops co-creation and design methods to help others develop evidence-based e-health solutions. She was recently appointed Medical Delta Professor and scientific leader within the Healthy Society in Medical Delta scientific program: lifestyle & prevention.