Behaviour change: digital and mobile health interventions

Why the committee made the recommendations

The committee discussed the lack of evidence surrounding which components and characteristics of interventions would lead to healthy behaviour change in different populations. This is common to all behaviours and is why the recommendations cannot be more specific. The committee made recommendations for research to fill this gap in evidence.

The committee noted that digital and mobile health interventions is a rapidly changing and developing area. As such, they agreed it was important to develop them in line with national supporting frameworks such as the NICE evidence standards framework for digital technologies to ensure they are as effective as possible. In addition, the committee agreed that the government digital service standard could be followed when creating interventions for public services.

The committee discussed the views from expert testimony that said many developers of these interventions do not have a background in healthcare. This is another reason why the committee wanted to stress the importance of using these advisory frameworks, as well as NICE frameworks.

In the committee's experience regarding approaches to behaviour change in general, the specific behaviour change techniques they recommended have been shown to be effective. But based on the evidence, the committee were unable to draw firm conclusions about how effective these techniques are when used with digital and mobile health interventions. However, they agreed that interventions with the listed behaviour change techniques are more likely to be effective than those without them. The conclusions of the committee also agreed with those in the NICE guideline on behaviour change: individual approaches, which notes that behaviour change interventions should include behaviour change techniques including goals and planning, feedback and monitoring, and social support.

The committee discussed and agreed that it is important for those developing interventions to consider their possible future use, which may be on a wide scale or much more localised. They agreed that it was important for interventions to be designed so that they can be scaled up and can be customised for local needs.

The committee agreed that people are more likely to change their behaviour using interventions that allow them to tailor goals to their needs. The evidence showed that interventions have variable effectiveness, and it is not clear which interventions result in positive behaviour change or in whom. So the committee agreed that developers should include tailored goals in interventions but should be transparent about how the interventions tailor more complex goals to people's needs.

NICE looked for evidence on adverse effects but did not find any. Based on expert testimony and their experience, the committee discussed interventions that may allow people to set goals that may be unhealthy for them. They were particularly concerned about the possibility of setting goals that would lead to the person becoming underweight, and the potential for this to cause disordered eating, exacerbate eating disorders or cause relapse. So they emphasised that interventions should not be designed to allow people to do this.

The committee were aware that developers have a responsibility to make information about their interventions clear. This allows people to make informed decisions on the interventions they choose. Some differences, such as ongoing data use after the intervention has been downloaded, are not obvious and may lead to unwanted costs for the user.

Based on limited evidence and expert testimony the committee understood that it can be challenging to get people to use these interventions on an ongoing basis. They agreed that more collaboration between developers, stakeholders and potential users would be likely to produce more useful and engaging interventions.

For example, if people with physical disabilities and sensory impairments or children and young people are given the opportunity to contribute, they are more likely to use the interventions, and the interventions are more likely to be effective. Some users may say how frequently they would prefer to use the intervention. For example, it could be a one-off intervention, multiple brief interventions or interventions that people interact with multiple times.

Owing to the impact of COVID-19, development might be conducted remotely using digital technology. This could mean that people who are not digitally literate may not be well represented. Developers should make efforts to include these people if possible, for example in design or testing.

The committee discussed expert testimony and agreed that interventions may be used differently after they have been released. This may mean components that worked well in development may work differently in real life. They agreed it is important to gather feedback after release to improve the intervention based on real world use.

How the recommendations might affect practice

Designing interventions that can be scaled up to be used by many people may help reach more people at a lower average cost. Wider implementation would allow local usage patterns to be monitored and services to be standardised between regions.

Developers will need to work with topic experts to develop content that meets evidence standards. This may mean sharing development costs with other organisations, which would help to reduce the resource impact.

Return to recommendations

Why the committee made the recommendations

There is inconsistent evidence that digital and mobile health interventions may be effective for behaviour change. There is insufficient evidence to suggest that they can be used instead of other services.

Some services that include face-to-face contact are currently being delivered remotely (such as by phone or video calls) by healthcare professionals while social distancing measures are in place. It is important to keep these services available, whether face to face or remotely delivered, to ensure that digital exclusion does not increase health inequalities.

The committee agreed that it is important that existing services are not simply replaced by a digital or mobile health intervention that may be less effective. There were very few studies that compared digital and mobile health interventions with usual care, which made it difficult to make a reliable comparison. But they recognised that the interventions could be effective for some people. So, they recommended considering them as an adjunct to other individual behaviour change services.

During the COVID-19 pandemic, many face-to-face services are being delivered remotely, such as by phone or video calls. The committee discussed the possible impact of this on the commissioning process, including the possibility that some services may be delivered in this way for an unknown time period, or possibly permanently. Commissioners may need to be aware of this possibility, assess any effects on health and wellbeing or on inequalities, and mitigate this.

The committee discussed the importance of differences in local populations and assessing local needs when commissioning a digital or mobile health intervention. These needs would be routinely assessed by a Joint Strategic Needs Assessment.

They agreed that these new technologies should cater for groups that face inequalities in accessing remotely delivered interventions. For example, by making them accessible for people with learning disabilities, problems with hearing or vision, mobility requirements, neurodevelopmental disorders, cancer, cognitive impairment, or mental health problems.

The committee also agreed that expert sources would only list interventions that have been assessed for safety, effectiveness and data security. So they highlighted the need to check those sources before commissioning any new interventions.

Commissioning the development of new interventions can be costly. By collaborating, trusts, local authorities and developers may be able to reduce costs. Collaboration could also lead to coordinated implementation so the interventions can reach a wider audience. Normal procedures and policies for collaborative working should be followed before starting development and when adapting an existing intervention.

Expert testimony suggested that interventions are often developed independently by either healthcare, policy or digital professionals, not collaboratively. Multidisciplinary teams would ensure that interventions are as useful and relevant as possible.

There was no specific evidence on equalities, but the committee agreed that not everyone may have access to digital and mobile interventions. An equality impact assessment can inform how interventions affect different groups. So, they made a recommendation to ensure that any communication, access and cost issues identified are addressed.

The committee were aware that interventions can contain adverts, some of which may counter the aims of the intervention and harm users. But interventions with adverts may reduce costs, thereby allowing more people to access them. On balance, the committee concluded that the benefits of adverts reducing costs for users outweighed the potential harms of inappropriate adverts.

How the recommendations might affect practice

Commissioners would use the NICE evidence framework and a needs assessment when choosing digital or mobile interventions.

Networks may be needed for collaboration between regions and people, which may need to be set up if they do not already exist. These networks will help to share costs.

Return to recommendations

Why the committee made the recommendations

The committee could not conclude which interventions and for whom digital and mobile health interventions would be effective on their own because of the variable evidence. They also noted that most of the evidence was not compared against current practice. Therefore, the committee agreed that they would not recommend that these interventions replace existing evidence-based services. But they agreed that they may be more suitable for people who want a more discreet tool to help change their behaviour or who cannot get to face-to-face consultations.

During social distancing, many face-to-face services are being delivered remotely, such as by phone or video calls. Digital and mobile interventions can therefore still be used as an adjunct to these services. The committee anticipate there may be a drift from remotely delivered non-digital services to digital-only services. Healthcare professionals should be wary not to push digital and mobile health interventions onto people they are unsuitable for, because this may exacerbate inequalities in some groups.

Based on their experience, the committee agreed that behaviour change is complex. The person's preferences and goals have to be taken into account alongside other considerations, such as in the COM-B model (capability, opportunity and motivation), to identify what type of interventions may be the most beneficial. It is important to discuss motivations because wanting to set unhealthy goals could indicate an underlying cause that needs to be treated.

In addition, if a consultation is conducted remotely during social distancing, healthcare professionals can assess and discuss with the person how comfortable they are with using technology for this purpose. If they are not happy using technology for this, digital or mobile health interventions may not be suitable for them.

Because digital and mobile technology is a fast-moving field, the committee agreed that in any discussions it was best to focus on components and characteristics rather than on specific named individual interventions. This is because individual interventions may become unavailable or their content may change.

The committee agreed with expert testimony that said users, particularly people from vulnerable groups, need to be made aware of certain issues relating to digital and mobile health interventions and how they work. For example, they may use the person's personal data if the person does not opt out of this option. There are many interventions available and the quality varies.

The committee discussed that potential users may trust digital and mobile health interventions more than other (non-health-related) digital and mobile technologies and believe that they are safer to use. So they may not be as alert to data security issues as they would be normally. Therefore, the committee recommended using interventions from an expert source, to reduce the risk to the user.

Data usage is another point to be aware of and is likely to be higher for interventions that continually track activity than those that only use data when they are first downloaded.

They also agreed that using digital and mobile health interventions may lead to some people having limited interaction with healthcare professionals and that this may not be suitable for everyone, in particular those in vulnerable groups. These include people being trafficked and young people who are vulnerable to sexual exploitation. Both groups may be kept hidden by abusers, using these apps instead of a consultation that would expose the person to authorities.

The committee discussed evidence from expert testimony that digital and mobile health interventions can lead to some unintended consequences, specifically to unhealthy behaviours such as disordered eating, excessive exercise or health anxiety.

The committee agreed that it was important to make healthcare professionals aware of these risks to try to mitigate them if possible. This can be done during the consultation when digital and mobile health interventions are first discussed and followed up at future appointments.

How the recommendations might affect practice

Extra time may be needed for healthcare professionals and users to discuss digital and mobile health interventions as an option for behaviour change. But after the initial consultation, because people use these interventions on their own, healthcare resources may be freed up for other activities. Use of these interventions may also lead to people not taking up other resource-intensive services. This may lead to cost savings. There may be increased costs due to adverse consequences of using the intervention, for example increased consultations related to increased anxiety.

Return to recommendations

Why the committee made the recommendations

Evidence showed that digital and mobile health interventions may help people to reduce their weight, increase their fruit and vegetable intake and become more physically active. The committee were confident that some interventions may work and some people would benefit from using them. But the evidence was variable, so they were not able to say which interventions would work or in whom. Therefore, they recommended considering these interventions as an option alongside other individual behaviour change services.

During social distancing, many face-to-face services are being delivered remotely, such as by phone or video calls. Digital and mobile interventions can therefore still be used as an adjunct to these services.

The committee discussed evidence and heard from expert testimony that self-monitoring may help people lose weight and become more physically active. This is because it gives people the opportunity to review their own progress towards their diet and physical activity goals. (See also NICE's guideline on behaviour change: individual approaches).

Expert testimony also warned that self-monitoring may be harmful to people who have, or who have previously had, an eating disorder or exercise addiction because it may become excessive. (Self-monitoring is part of disordered eating and excessive exercise.) So the committee agreed that interventions without self-monitoring might be more appropriate for this group.

How the recommendations might affect practice

Professionals need time and resources to check that potential users are not at risk of harmful behaviours by using these interventions, especially if they contain self-monitoring aspects.

More people using digital or mobile health interventions may mean fewer face-to-face appointments, making resources available for other services and saving costs.

Return to recommendations

Why the committee made the recommendations

There was evidence that digital and mobile health interventions can help people to stop smoking, although it was unclear which interventions and in whom they would work. Most of the evidence did not compare against typical services for smoking cessation in the UK. On the basis of the evidence, the committee recommended considering these interventions as an option alongside other individual behaviour change services.

During social distancing, existing face-to-face services are being delivered remotely, such as by phone or video calls. Digital and mobile interventions can therefore still be used as an adjunct to these services.

The committee discussed the limited evidence that suggested that interventions using tailored text messages may be more effective than other digital and mobile health interventions. They used this and their expertise to agree a recommendation on the use of tailored messages. There was also evidence that using text messages as a supplement to usual care was cost effective.

The committee agreed that interventions developed or funded by the tobacco industry are not appropriate. This is in line with NICE's obligation under Article 5.3 of the World Health Organization Framework Convention on Tobacco Control to protect public health policies from the commercial and other vested interests of the tobacco industry.

How the recommendations might affect practice

More people using digital or mobile health interventions may mean fewer face-to-face appointments, making resources available for other services and saving costs.

Return to recommendations

Why the committee made the recommendations

There was limited evidence that digital and mobile health interventions can help people reduce their alcohol intake. But the committee agreed that some interventions may work and for some people, so they recommended considering them as an option alongside other individual behaviour change services.

During social distancing, existing face-to-face services are being delivered remotely, such as by phone or video calls. Digital and mobile interventions can therefore still be used as an adjunct to these services.

Some evidence showed that presenting people who drink at hazardous levels with details of how much they consume may help to reduce their drinking. Effective components may be different from person to person based on their lifestyle and health.

Limited evidence showed that interventions that people need to interact with several times were more effective than one-off interventions – although a one-off intervention is more effective than doing nothing. Because the committee did not want anyone to be excluded from the advice provided, they made a recommendation to reflect this.

How the recommendations might affect practice

More people using digital or mobile health interventions may mean fewer face-to-face appointments, making resources available for other services and saving costs.

Return to recommendations

Why the committee made the recommendations

The evidence identified covered several populations including adolescents, men who have sex with men, people with HIV and university students. But because it was very limited, the committee agreed that they could not make individual recommendations for each of these groups. Most of the evidence related to online brief interventions (for example, a 15-minute interactive condom use intervention). There was limited evidence that these interventions showed some effectiveness in helping people change their sexual behaviour.

Limited evidence showed that interactive videos can help people change their sexual behaviour. These are scripted scenarios that need the person to take part in the story. Dramatisations, with the person just watching the story, are also effective. The committee agreed that people putting themselves in these 'virtual' situations allows them to experience difficult sexual situations and develop healthy response mechanisms that can be applied in real life. The committee also agreed that this approach is unlikely to be as effective for changing other behaviours because it works well for sexual behaviour in particular.

The committee were aware that some interventions may contain sexually explicit content. They were also aware that some people should not or may not want to view this material. They agreed that raising awareness of this issue would help people choose interventions that are appropriate for them.

The committee agreed that they would only recommend that people consider these interventions, and only as an option alongside other individual behaviour change services, for people who are considered to be Gillick competent (see the Department for Health and Social care's reference guide to consent for examination or treatment for information on Gillick competence).

During social distancing, existing face-to-face services are being delivered remotely, such as by phone or video calls. Digital and mobile interventions can therefore still be used as an adjunct to these services.

How the recommendations might affect practice

More people using digital or mobile health interventions may mean fewer face-to-face appointments, making resources available for other services and saving costs.

Return to recommendations

Why the committee made the recommendations

There is limited evidence on why and when people engage with and disengage from digital and mobile health interventions. This is important because initial engagement is lower in people with lower socioeconomic status, and there may be other members of the population not currently visible to services.

The committee agreed that research into ways that healthcare professionals can identify and encourage people to engage with and continue using digital and mobile health interventions is needed (see the recommendation for research on engaging people with digital and mobile health interventions).

The committee was aware that specific components or characteristics may be more effective at changing or targeting specific behaviours. Evidence on this is complex, and digital and mobile health interventions is a rapidly changing field. The committee agreed that research is needed to evaluate the effectiveness of specific components and characteristics (see the recommendation for research on effective components of behaviour change interventions).

There is limited information on the effectiveness of digital and mobile health interventions for different socioeconomic groups, people with disabilities or underserved populations. The committee discussed the potential difficulties with recruitment and possible additional costs associated with reaching underserved populations. They agreed that more information on this topic would help to tackle health inequalities (see the recommendation for research on effects of behaviour change interventions on low socioeconomic and other underserved groups).

The committee agreed that, as the field develops, it will be helpful to know if there are specific groups that may get as much benefit from digital and mobile health interventions used alone as they would from existing services. This question is more significant in light of the current context of the COVID-19 pandemic because the committee expect more people to consider using remote interventions (see the recommendation for research on populations that will benefit most from digital and mobile health interventions).

No published evidence was found on adverse effects or potential harms for any of the behaviour change areas considered. The committee discussed this and heard from expert testimony about potential harms related to digital and mobile health interventions. The committee noted that more published research is needed on harms, adverse effects or unintended consequences (see the recommendation for research on harms of behaviour change using digital and mobile health interventions).