Since the release of iPhone and the mobile revolution (late 2000’s,) the health and wellness space has gone through major transformations. Having a smart phone in everyone’s pockets meant that you could load up that device with all kinds of apps that serve different needs of our everyday lives. Health is no different. There are all kinds of possibilities to move health and healthcare out of the doctor’s office and into our daily lives. After all, our health outcomes are tied to what we do everyday and not what happens in the doctor’s office. The early health apps that became available on smart mobile devices dealt with the exact types of things that have a major impact on our health: diaries for journaling our food, step trackers for our activity levels, mental health journals to record our thoughts and feelings, and more. Looking back now, the concepts behind those apps were exactly the same as the ones behind the tools today.
In the early days of digital health, there was an expectation on the part of the healthcare community that these tools could be a major breakthrough in population health management. If people are aware of the number of steps they’re taking and it’s well under their goals, they will become more active. If people notice that their food diary shows too much salt and they have high blood pressure, they will adjust their diet. If their diary shows that they have irregular sleep patterns and they feel tired during the day, they will adjust their sleep patterns. Another words, if you have more data and feedback, you would automatically make the needed adjustments and nudge your health in the right direction. Of course, none of this has played out the way we expected and even today, when the sophistication of the gadgets has increased dramatically, we don’t see people making the kind of lifestyle adjustments that really moves the needle.
How do we explain all of this? How could so many people with deep expertise in this space have miscalculated the health impact of these new tools? The explanation for this requires us to understand the larger context of our society and modern lives. In fact, what our experience over the last 15 years has revealed is that many of our daily choices have less to do with our lack of knowledge or will power and more to do with the realities of our lives. For example, if you’re eating most of your meals in restaurants because of your job, it’d be very difficult to eat healthy. You don’t have any control over the oil that’s used to cook the meal with (cooking oil is a major driver of high cholesterol and triglycerides,) how much salt is added to the food, other unhealthy ingredients added to make the food taste better, etc. So, you can have the best of intentions about eating healthy but the demands of your job keep you from being able to fully control that and consequently you end up eating less than healthy most of the time!! The same can be said of your exercise habits, sleep, stress levels, and other health drivers. Exercise is hard to include in your schedule if you have to work long hours and take care of your family. Stress level is hard to manage if there are significant external realities such as a stressful job or marital issues. So, while having more data and ongoing feedback will be helpful to some people (usually the very motivated who are already healthier than most people,) most people are still trapped within the realities of their daily lives and can’t do much with this information.
After these apps and wearables became available and people had a chance to use them for a few years, what did the research show about their impact on the users’ health? A close examination of some of the best studies clearly shows that access to health apps or tools like wearables do not necessarily lead to better health outcomes. In a study published in Nature, the use health apps or wearables did not improve to better outcomes at the population level. Digging into the key details of the study, which covered US, China, and Singapore, income level had the strongest association with mental and physical well being and digital health tools had very little positive impact on these measures at the population level. The study emphasizes the importance of considering the social determinants of health (SDOH) and social–cultural context of the population. SDOH are increasingly being considered and addressed in order to achieve better health outcomes at the individual or population levels. What are social determinants of health? Well, they are non-health issues that can have a strong impact on people’s health. Examples include income level, housing security, food security, health literacy level, mental health, access to transportation, domestic safety, and more. Each one of these issues can lead to worse health outcomes as they can affect people’s behaviors.
Source: Mayo Clinic Proceedings
If you’re depressed or do not feel safe in your home, it is exceedingly unlikely that you would actively participate in managing your health. Long-term health requires ongoing healthy behavior, engaging with the healthcare system, following medical instructions, and more. As such, SDOH have a disproportionally high impact on health outcomes. It is in this context that we need to examine and understand the impact on digital health tools and the cool new gadgets on health outcomes. If people who have higher income and higher health literacy, who are also more likely to have access to these tools, will further benefit from quantifying their activity, caloric intake, sleep quality, and other key metrics, then the healthy will become healthier by using these tools. For those who are already struggling with the demands of their daily lives, having access to a smart watch or ring may not make much difference since they are unable to act on the data it collects. This is exactly wha the Nature study showed and that has been the general experience of the medical community. I saw this firsthand when I ran a population health management technology company for years and saw how socio-behavioral barriers can trump technology in preventing better health outcomes.
In the next post I will get into the evolution of these gadgets and whether the learnings from the past 15 years are resulting in better products that can lead to better population health.
