Your health, yourself: Conclusion

In the concluding part of this series by Ogilvy CommonHealth Worldwide on the quantified-self movement, we review what we have learnt by meeting our five patients with their separate health concerns.

(Continued from "Your health, yourself: Harry's inherited health")

We live in the age of the individual. It may have started off modestly, with the ability to choose your mobile ringtone or customise your desktop wallpaper, but in recent years the trend has grown exponentially – to the point where self-expression now reigns supreme. As consumers, the 21st century offers a seemingly limitless array of opportunities to personalise not only how we interact with the world, but the very way the world interacts with us. So why shouldn't the arena of health follow suit? After all, we already possess a naturally proactive interest in our own existence. And if you combine this with the age-old desire to categorise, monitor and analyse aspects of one's own life – think banking, bills, time management – it seems pretty obvious that we might want to pay closer attention to our vital statistics.

Take the formidable rise of the 'e-patient' as case in point. At this moment, millions of individuals around the globe are frantically clicking away on the Internet or any one of its interconnected tools in an effort to seek out, share and sometimes create their own information about health and wellness. And whilst to date this phenomenon has mainly focused on the distribution of medical knowledge to the masses, the latest developments are more intimate. How much do you know about the 'Quantified Self' concept? If the answer is 'not a lot' then listen up. To quantify oneself in regards to health means to gain a deeper (often numerical) understanding of one's body as a machine. More specifically, as a unique machine driven by distinctive data. It can mean knowing how high your body mass index (BMI) is or how low your cholesterol is. It can mean (accurately!) tracking weekly kilometres jogged or five-a-day consumed. It can mean taking the medication designed for your specific DNA, not that of your neighbours.

"How much do you know about the 'Quantified Self' concept? If the answer is 'not a lot' then listen up."

And in all of these pursuits, self-quantification makes use of the latest advances in digital technology to provide users with the most personalised and precise service possible.

What is for certain is that the future's here, and it wants to get to know you. The real question is: should we let it? After all, configuring your latest smartphone or tablet to reflect each quirk of your individuality is pretty harmless, but the same may not be said when we let people tinker with their own complex biology.

The case for more personal health information

When it comes to our health, we are often our own worst enemy. Some of the greatest threats to our general wellbeing, like obesity, heart disease and sexually transmitted infections, are more often than not brought on by personal lifestyle decisions. Some governments have enjoyed moderate success with smoking bans and taxes on high fat foods, but the hard truth is that truly effective change has to start with the individual.

You know those public health campaigns which gently hint that it would be wise to limit our salt consumption or aggressively shock us with pictures depicting the grotesque consequences of smoking cigarettes? Well, the evidence suggests that too many of us just aren't listening. And even if we do listen, we very often don't do, even when faced with a concrete diagnosis. Physicians constantly struggle to combat low adherence to the necessary lifestyle changes and medication prescribed to patients with serious chronic diseases, such as diabetes and arthritis. And if you think this situation might improve any time soon, think again. Medical resources across the globe, not to mention the healthcare professionals who deliver them, are becoming increasingly stretched as the general population ages by the second. Relying on national health systems to provide individual attention to each and every patient who demands it is no longer a realistic solution. Which all leads to one very stark conclusion: health behaviour change is now a critical issue.

"When it comes to our health, we are often our own worst enemy."

So how do we stop being enemies and start making health our new best friend? Quantifying our health, ourselves, could well be part of the answer. If delivered smartly, personally relevant health information might not just motivate us more, it might actually help us (finally) understand and appreciate the risks and rewards of our daily behaviours. Would knowing the effect a mid-morning packet of crisps has on our blood pressure provide us with the willpower to reach for an apple instead? Would we pass the bus stop and walk home if we knew that they were all the steps needed to reach our daily target? Would we stick to a daily prescription if the doctor told us that the benefits were greater for our particular genetic profile? Perhaps. After all, studies in diabetes, hypertension, medication compliance and weight loss have shown that patients who successfully self- monitor their activities and set personal goals enjoy improved health outcomes and higher levels of adherence to treatment1-6.

If this is the case, the good news is that today's wired up society is well prepared to take on the self-quantifying challenge. Armed with our smartphones (which are estimated to be within our reach 75% of the time7), we have an abundance of apps at our fingertips to comprehensively track aspects of our lifestyles, analyse results and observe improvements over time. These self-monitoring tools can then be easily integrated into social health networks so that as patients we can share experiences and advice on the best treatments.

One such peer platform is known as The Quantified Self (QS) Movement. With over 5000 members in 42 countries8, worldwide groups have regular meetings where data is compared and different devices and quantifying approaches reviewed. The Movement is growing rapidly, with the most popular tracking tools focusing on diet, weight, fitness and sleep patterns. Members of the QS Movement are well aware that focusing on your health, yourself, can bring a number of benefits. Instead of relying on personal impressions and memories to keep track of health behaviours, they make use of devices that hold vast quantities of accurate data and automatically identify patterns and trends. When this data is analysed effectively, personal risks can then be clearly articulated and contextualised for individuals, and health gain meaningfully mapped out over time.

"...health behaviour change is now a critical issue."

The case against more personal health information

It all sounds very promising doesn't it? But before we all yell 'sign me up!' and jump aboard the self-quantifying bandwagon, a few words of caution...

What about the people who are unable to reach the goals their personalised tracker sets them? If a target weight or blood glucose level remains unmet, the overriding result is likely to be frustration or disillusionment. In fact, a recent study into self-monitoring to improve diabetes treatment found that the main concerns that patients had with the system were disappointment with unmet expectations and difficulty fitting the programme into the demands of daily life1.

What about the people who feel pressure sharing results with peers on a social networking site? It is one thing not to reach your own goals in private, but quite another to fail when others are watching. Some high-level users may even put themselves at risk of harm in order to keep up the competition. One such case is that of William Flint, a man who was killed while racing down a hill in an attempt to regain the top ranking on a cycle-tracking app called Strava9.

What about the people who take self-monitoring too far and become obsessed with keeping track of daily habits and behaviours? Even if they don't push themselves to injury, fixating on one aspect of their lifestyle that is perceived to be at fault can lead to increased stress and the propensity towards unnecessary self-diagnosis7.

What about the people who are weary of further intrusion into their ever- increasingly less private lives? Rather than put up with more interference from the public or private sector in regard to their health, these people may simply prefer to ignore the noise and bury their heads firmly in the sand.

And finally, what about the people who don't have sufficient knowledge or understanding to analyse the data that they have been provided with? If comprehension is insufficient, then there is a risk that the user will tend towards finding faults with themselves that may not exist. So if the user has a tendency towards self-treatment (as may be suggested by their enthusiasm for self- monitoring) then this could at its worst lead to self-prescription, thereby doing more harm than good10.

So it's safe to say that any serious approach to self-quantification has to keep these potential risk areas firmly in mind. But the popularity of the QS Movement also suggests that the method is working for a substantial sector of society – so what lies between success and failure? The manner in which personalised data is delivered is vital.

The apps which make the process of data upload as effortless as possible for the end user are the ones most likely to catch on in the long term. Currently, many tools require manual updating of records, which is not only intrusive but takes precious time out of a person's day7. This makes it unlikely that data entry will be routine, resulting in sporadic and fragmented records of events. The more sophisticated devices automatically record data and the best even synchronise it with online analysis programmes in real time – providing a seamless transition with minimal disruption to the user.

"But the journey towards a fully functioning personalised medicine approach has not, and will not, be easy."

Aside from the effort to upload data, a common barrier to self-tracking is simply a lack of interest or understanding. This means that health information needs to not only be engaging, but also simple enough to be universally accessible.

The average person is likely to find sorting the data that matters from what doesn't time consuming and intellectually daunting – in fact, many patients who have to actively monitor a condition like Type II diabetes don't always fully engage for these very reasons11. Plus we can't realistically expect doctors to start using precious consulting time to clarify statistics that are proving too mystifying for their patients.

One way to remain motivating and practical is to explain both immediate and long-term health risks and benefits in a straightforward yet inspiring manner. Establishing aspirational but realistic goals and providing self-efficacy reinforcing feedback against the attainment of these goals can help bring self- monitoring systems to life, making them personally meaningful on an ongoing basis. And if we can achieve this holy grail then maybe even those with their heads in the sand might not want (or be able) to ignore us any longer. Of course, that's not to say that the fear of intrusion and the question of Internet security should be ignored – many studies show that computer concerns are one of the major attributing factors to the low uptake of digital monitoring tools4.

Health highlights:

• Health behaviour change is now a critical issue.

• If done well, the provision of more personally relevant health information can effectively change health behavior.

Do:

• Base strategy on well-founded behavioural change theory (particularly goal theory and self-regulation theory) and evidence published in reputable journals

• Promote achievable, tangible health rewards and demonstrate concrete, realistic risks, all the time allowing consumers to set goals and receive feedback

• Make sure data is well visualised, (for example with clear and compelling infographics) and contextualised to the user's life

• Facilitate simple, straightforward data collection that requires minimal manual effort

• Enforce tight security to protect privacy

Don't:

• Overload and overwhelm people with information, thereby boring them, or even worse, alienating them from the task altogether

• Encourage patients to take self-monitoring to extremes or misunderstand its output, thereby negating any positive effects and causing additional health or psychological issues.

References

1. Barlow J, et al. Self management approaches for people with chronic conditions: a review. Patient Educ Couns 2002;48:177–87.

2. Benhamou PY. Improving diabetes management with electronic health records and patients' health records. Diabetes Metab 2011;37(Suppl 4):S53–6.

3. Dennis EA, et al. Weight gain prevention for college freshmen: comparing two social cognitive theory- based interventions with and without explicit self-regulation training. J Obes 2012;2012:803769.

4. Parker R, et al. An electronic medication reminder, supported by a monitoring service, to improve medication compliance for elderly people living independently. J Telemed Telecare 2012;18:156–8.

5. Ralston JD, et al. Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study. BMJ 2004;328:1159.

6. Wagner PJ, et al. Personal health records and hypertension control: a randomized trial. J Am Med Inform Assoc 2012;19:626–34.

7. Lathia N. Using idle moments to record your health via mobile applications. Available at: http://www. cl.cam.ac.uk/~nkl25/publications/papers/lathia_mscss12.pdf (Last accessed May 2013).

8. Swan M. Crowdsourced health research studies: an important emerging complement to clinical trials in the public health research ecosystem. J Med Internet Res 2012;14:e46.

9. Forbes. A quantified self fatality? Family says cyclist's death is fault of ride-tracking company strava.

Available at: http://www.forbes.com/sites/kashmirhill/2012/06/20/a-quantified-self-fatality-family-says- cyclists-death-is-fault-of-ride-tracking-company-strava/(Last accessed May 2013).

10. Santana S, et al. Informed citizen and empowered citizen in health: results from an European survey. BMC Fam Pract 2011;12:20.

11. Choose Control Survey. Choosing to take control in type 2 diabetes. Available at: http://www.diabetes.org.uk/Documents/Reports/Choose_Control_report.pdf (Last accessed May 2013).

Other articles in this series:-

Your health, yourself: Thiery's technotraining

Your health, yourself: Marta's nutrition mission

Your health, yourself: Claude's case of compliance

Your health, yourself: Dana's daily dose

Your health, yourself: Harry's inherited health