Part 2 – Interview with Jessica Dorazio, Product Designer at Ayogo:
M: So today we’re discussing how a smartphone can fight harms to the health and wellbeing of vulnerable populations. What is it that you find particularly interesting about this topic?
J: One reason I’m interested in this topic is I think I’ve increasingly grown to understand how health is multidimensional – encompassing physical health, mental health, and someone’s quality of life. Every single aspect of our lives depends on us having good health. I’ve personally had several health challenges in my life, but I recognize that I’ve been in a place of privilege when dealing with them. I also have the privilege of having the tools and resources to invest in my health – contact professionals; eating right; exercise, take a sick day from work, and not worry if I’m not going to be paid; work from home, etc.. This is not the reality for so many people, and if I didn’t have this privilege, the outcome of some of my own experiences would’ve undoubtedly looked quite different.
At the same time, through the projects I’ve been involved in and being in digital health, I’ve gained a deeper understanding of the power of technology to drive change – both bad and good. There’s a lot of attention out there today on how ChatGPT and LLMs will change the future of our occupations and technology in general with respect to those in the middle class or above, and among generally those who don’t face a complex health condition. So I’m interested in the potential of a particular area of technology, like a smartphone, on those that face disparities and are vulnerable populations overall.
Through my role at Ayogo, looking into new markets where our product can be applied, it’s apparent there are multiple contexts in which disparities exist, and maybe some of this can be addressed by something most of us have today and carry with us daily – a smartphone.
M: So, what’s the significance of the smartphone specifically?
J: That’s a great question – I think there are two more or less universally accepted truths when it comes to our smartphone. Number one, our devices are manipulating us every day. They influence how we think and behave, the vast majority of which is imperceptible to us. It’s below our layer of consciousness. As such, we don’t even know we’re being manipulated. And we should recognize that the desire to captivate our attention is often in the hands of powerful companies with an interest in profiting off our behaviours.
The second more or less universally accepted truth when it comes to our smartphone is something that really surprised me. It’s how it’s actually a basic need. Smartphones have become this thing that’s essential to functioning in society. In fact, many people from lower income households only use their smartphone to access the internet and forfeit other options.
In 2021, 20% of adults living in households earning less than $30,000 a year were actually smartphone only internet users, meaning they own a smartphone, but they don’t have broadband internet access at home.
So we’re in a world today where one of our basic needs is constantly nudging our behavior. And then on top of that, there’s an accelerated migration of our lives online as a result of COVID and the need to social distance. In fact, one third of our waking hours are spent tapping, clicking and scrolling on our smartphones.
I think there’s a misconception that mitigating harm involves limiting use of this device, but what’s often not considered are how factors like its prevalence and its ability to influence people could make it the ideal tool in, in some circumstances to mitigate harm- depending on how it’s used.
“One thing I’ve learned is that the majority of health outcomes actually stem from non-clinical factors. These include psychosocial factors like beliefs and attitudes, emotions, social support, and healthy coping skills”
M: So what kinds of approaches; what kinds of tools or tech do you think is going to make the difference?
J: In terms of the approach, what I’ve seen is it’s important to start by looking at the big picture of what’s driving someone’s health and behaviour. One thing I’ve learned is that the majority of health outcomes actually stem from non-clinical factors. These include psychosocial factors like beliefs and attitudes, emotions, social support, and healthy coping skills
So with this in mind, there’s several strategies we can deploy. When someone experiences an unexpected moment of surprise or delight, we have the opportunity to disrupt patterns that exist in their internal operating system.
On a micro level, we can use this to change someone’s mental state – their resilience, motivation to take action, and how supported they feel. On a macro level, we can actually help people to make more deliberate positive choices in their life.
This is opposed to the current state – Most people are receiving notifications and nudges on their phone that influence them to one extent or another. Most of these nudges aren’t looking for opportunities to improve their situation. But, what if they could? At first, this whole idea struck me as a paradox. How could a tool designed to influence someone have the effect of helping them to make more deliberate intentional choices? However, I saw how this was true, and someone who previously could not consider different possibilities when it came to changing their life circumstances could be empowered with options to change their situation.
“At first, this whole idea struck me as a paradox. How could a tool designed to influence someone have the effect of helping them to make more deliberate intentional choices? But, I saw how this was true, and someone who previously could not consider different possibilities when it came to changing their life circumstances could be empowered with options to change their situation.”
M: Depending on how it’s used, and presumably depending on who is doing the using of it… I mean, how do we ensure that there are only good actors, or that mostly good actors, or how do we ensure that good actors have access to this technology at all? I mean, what should be done to make it better than it is?
J: You brought up a really excellent point when we were speaking earlier that we regulate who is allowed to call you on the phone or send you an email through spam filters. So, we see regulation on who can message you in many areas of our lives when it comes to broadcasting messages… We can’t just put a TV show on the air. There’s a lot of rules around what can be shown and what’s allowed at different hours.This means there’s a lot of precedent. I think it’s in part a policy question, and I’m sure we could do another entire podcast on the topic of how we decide who has the power to control the algorithms that influence our lives. But,I do feel there’s an important place for a more public dialogue on how our devices impact our brains.
We should be informed of the power the tools that we use have on us – What are the potential effects on our minds, bodies, and behaviours? So overall, I’m by no means an expert in this area, but to me, I feel like there’s a greater need for public dialogue in hand with policies that create accountability.
M: Yeah, not to be cynical, but we haven’t been very good at factoring in those negative externalities in our current environment. You know, there’s plenty of toxic waste being put into our physical environment and I guess there’s still a fair amount of toxic waste, if you want, being put into our digital environment. So, maybe you can talk about the significance of that messaging a little bit more. In what way is digital messaging equivalent to, you know, environmental factors? I mean, we often don’t think of the digital space as like an environment in which we are living, but it really is.
J: The words that we say to one another, and we hear matter – and subtle differences in the messages someone is exposed to, and the language that they hear can impact their state. And importantly, we don’t wanna send someone the wrong message based on their state, because doing so will have a ripple effect of having, being a huge turnoff, and train them essentially to ignore future messages from you.
As an example, think of your favorite apps on your phone that send you notifications. Let’s say UberEats sends you a notification every day at 12:00 PM every single day to coincide with your lunch break. It’s timely, but it’s predictable and it’ll be predictably ignored when our brain comes to expect it.
And as another example – have you ever driven to work but can’t really remember anything about the journey getting there? There’s the same science involved. Our brain needs to have selective attention focusing on one thing while disregarding others to preserve it for what’s important. It knows that absorbing all the details, the trees lining the road, the homes that you pass, the turns you take are not relevant for the most part. And our expense of attention and focus needs to be spent on not crashing. So to get through to someone, you actually need to defeat this filter.
M: Yeah, I mean, in that example you gave about Uber Eats – it’s timely for sure. And, you know, if it’s also relevant, then that may be enough for me to begin to habituate using Uber Eats for my lunch – if I’m a person who eats out for lunch all the time. If I’m a person who doesn’t, then it’s not relevant to me and I will very quickly learn to ignore those messages. And so therefore, messages that I may get from Uber Eats at other times may not get through because they’ve habituated me to ignoring their messagesI think you made the point there that personal, relevant and timely are all really necessary to get, and hopefully keep a person’s attention. What impact do you think that this has for underserved and vulnerable populations in particular? How do you see that factoring in?
J: Yes, I’d love to share a few examples and, and to answer this question.
Let me try to paint a picture of what this might look like. Let’s take the case of a young woman named Lena. Lena is 19 years old and pregnant with her first child. She currently has two jobs, but she’ll need to quit when her baby comes. She’s stressed and confused, and you, she doesn’t have a strong support network. Where will she live? What does she need to do to stay healthy while pregnant? And, how should she prepare for her baby? Lena has researched how to prepare. She’s seen a doctor, but she’s too overwhelmed with different opinions to develop an action plan. She doesn’t have health insurance, so she’s leery to go back and consult a doctor again. I’ll just pause there…
This picture doesn’t even go into discrimination based on race or gender or psychosocial factors like stressful living circumstances or perceived self-control and mental health impacts, like adverse childhood experiences that impact current behavior. In just this case, you can see that health, well, it’s complicated and Lena suffers because she’s not experiencing a system that was designed for her or is capable of proactively addressing her unique needs.
Here’s where a digital program has the unique opportunity to make a difference. If we were to think for a moment of where the products and services that we interact with today are personalized to us, what systems know us best (maybe even better than, than we know ourselves!) The first thing that comes to mind is probably something digital-, social media, technology companies, e-commerce. In the same way, we can cultivate a personalized experience for each patient, or human service program participant that takes into consideration things like their unique context, their environment, and psychology.
If I were to recast Lena’s situation: Let’s imagine a scenario where Lena has personalized digital support. This support could be used to reduce her stress, and build her confidence while it guides her through setting and achieving milestones that she needs to attain health and prepare for her baby. We could also present Lena with resources, and options to make deliberate choices to improve her life situation as a young mother by helping her to navigate things like financial planning, housing, finding a job or, or maybe even getting further education, or other areas of her life.
M: Yeah, interesting. So, what is kind of specific about the smartphone? Is it just its presence in Lena’s life? it’s always there in all these various moments. She can get smaller bits of support, smaller but more regular moments of support in her life.
J: It’s actually a lot more than its presence; it’s about how we can personalize and tailor information, and interventions. There’s a lot of say on this, but let’s look at one specific area as an example: goal setting.
Many evidence-based programs exist to support people in both clinical, and human services settings that have goal setting as a core part of their programming.
There’s a power dynamic between a coach, and a program participant. The coach is generally supposed to be a guide and a mentor and, and is the keeper of information related to a participant’s progress. The participant is being told what to do.
One thing I’ve seen is that technology gives vulnerable populations confidence in goal setting. Through digital delivery, we can make an impact in shifting that power dynamic. We can give participants more control over the entire experience while they’re engaged in their daily lives – exploring goals that are meaningful to them, and a good fit with their resources and interests. They’re able to have more ownership. Be right there in the driver’s seat beside their coach.
Also, goal setting is no longer an event. It’s no longer a static process that occurs when a coach and a participant are together. It’s become a more open process where there’s shared information and progression tracking.
We’re able to extend the presence of a coach in someone’s life – when pursuing goals gets difficult and someone is overwhelmed amid complicated and busy lives.
It’s also giving program participants empowerment through contextually relevant resources that they need to achieve their goals in the moment, allowing them to take action steps with those resources in hand while they’re pursuing their goals.
M: Yeah, goal setting is not easy, right? It’s, it sounds like a simple thing. You imagine everybody’s got goals, but actually most people have aspirations, they don’t really have goals, they don’t have well stated, well structured, well organized goals. So talk about that part of it – goal setting, and how to help Lena use this tool effectively.
J: I’ve learned what’s required to address psychosocial factors – those factors with the majority of influence over someone’s outcome – is traversing from one state of being to another. I can’t say where or how I am today. I need to make behavior changes, reach out for support and assistance, and adopt new modes of self-care.
Goals in healthcare settings are not new, but these goals are often related to taking medication as prescribed, or maybe clinical measures, like blood pressure or weight. Where this can actively address disparities is when goal setting extends beyond clinical factors.
An important learning for me is that goal setting processes are often not nearly as effective as they could be – They’re really apt for a digital environment. While goal setting is not new in clinical settings or by evidence-based programs, it’s often paper-based. It’s often in a worksheet. And as a program participant, I may struggle to fill it out and if I want to share a copy with my family or my care team, I’ll actually need to make a photocopy.
In a digital environment, We have the ability to do a lot of things. One of those is to ingrain a S.M.A.R.T. goal setting structure to support effective goal setting.
Using digital delivery, what we see is that paper-based task lists and, and binders of educational material become, are articles and videos that are designed to be informative, but also contain humor and, and real stories from other patients who’ve overcome similar obstacles. Through digital delivery of goal setting, we can transform the process from one that’s typically stressful and often overwhelming into an experience that’s reassuring, builds motivation, and ultimately is designed to be as useful as possible in difficult circumstances.
M: So goal setting is important and crucial, and digital tools can help with that; helping us organize our thoughts, and so on. But, you haven’t mentioned anything about a ‘digital coach’ exactly. Who is on the other side of that conversation? Who is supporting patients to set and achieve their goals?
J: A common question is, should goals related to non-clinical factors actually be something a clinician should be addressing? And the answer in most cases is no. Actually, it’s probably not a good use of a doctor’s time. They’re likely not equipped in these areas that are non-clinical in nature.
This is an opportunity for innovative technology, and non-healthcare professionals to make an impact. In healthcare settings, goal setting typically takes place when a multidisciplinary care team works with a patient, which might involve a health coach, a nurse, a counselor, a dietician, and social work coming together to support a patient.
In the human services sector, evidence-based programs that support vulnerable populations today often rely heavily on coaching. A great example of this is New Moms, an organization in the Chicagoland area serving first time mothers, experiencing poverty – nearly half of which are homeless when they arrive at New Moms.
M: So how can this be used specifically to help vulnerable populations?
J: Goals become tools that guide vulnerable populations in a number of ways. One way is they can be personalized to acknowledge differences in abilities, and resources complimenting someone’s human journey that they’re going through.
For vulnerable populations, those goals might include basic needs like budgeting for reliable transportation or financial goals like applying for Women, Infants, and Children (WIC) benefits, or goals related to nutrition, and employment and, and so much more.
M: Interesting. So, making it relevant to the life circumstances of an individual person is necessary to make this not feel just like a generic tool, right? You’re really talking about something that’s, you know, deeply embedded in my life and really, you know, highly personalized to my own needs and circumstances. talk a little bit about that personalization and, and its role in all of this.
J: A patient or a program participants can experience a system that’s dynamically tailored to their life circumstances. So I’ll give you a really precise example of this: say someone has an abusive partner and unstable living circumstances. It may not be the first thing that comes to mind, but their housing in this case and their relationship will play a huge role in their ability to follow their care plan.
Each of us, if we think about it, has a unique decision making context, and that includes a set of influences, circumstances and beliefs that drive our decision making about our health.
So if you think about your experience with Facebook, for example, it’s really good at keeping our attention because it presents us with a stream of interestingness every time we log in. Your feed is based on variables like what you like and your interests. It also considers historically what you pay more or less attention to. And it’s not predictable because it’s always changing and, and serving up what’s new, a continuous relevant stream. And a key part of this interestingness is relational. So it’ll show you what your friends like, and it’ll highlight that activity in a way that it thinks will be meaningful to you.
When it comes to at-risk vulnerable populations, a version of this concept is to dynamically tailor their digital experience. If we can captivate, keep someone’s attention, and then focus that attention on the most critical aspects of their life and the things that can be done to improve their circumstances, that’s how we can, really make an impact and improve their confidence as someone going through a vulnerable circumstance or, or disparity or facing a disparity is pursuing their goals.
M: Makes sense. In that context then, collaborating effectively with coaches and your care team, becomes really essential, right? We’re talking about, you know, personalizing. To me, that’s fine. I understand how you can make a system be more personal, but at a certain point, you need clinicians and coaches and other people to also be making decisions to decide what to do, and to be influential in the process. How do we ensure that people’s values and motivations, and so on, are aligned? How do we collaborate effectively between patient and coach?
J: Yeah, we should talk about how human beings actually play an essential role. Digital tailoring is not enough.
The reality is that people face varying degrees of human support. I’m particularly interested in how human aspects of communication, and human support can be amplified by digital health. And I’m not talking about AI or robots mimicking actual human connection. I’m talking about the actual connection between human beings.
Tailoring should be a collaborative process that involves algorithms, but also needs to involve human beings. A multidisciplinary care team and coach are part of the tailoring process. Based on their relationship with a patient, they can shape things like their next best action. They can recommend goals and activities for that person to do and even help them with pre-appointment preparation. So there definitely is, is a crucial role of, of human beings working with algorithms.
If we were to think for a moment about where the biggest impact on the action plan for health occurs, if we think about it, it typically happens in an appointment. An appointment that often doesn’t last more than 15 minutes. And in that time, plans are put into place, prescriptions may be ordered, or you may be sent to go do some tests and therapeutic guidance will be given. And, when appointments do happen, healthcare professionals miss a lot of context on what’s going on in that person’s life. This is a well-documented limitation of modern healthcare.
What if we could take those interactions – that are often stressful for a patient and don’t illuminate the big picture for a healthcare professional – remove time and space?
M: Interesting. So, okay – Any example you can give me an example of that.
J: So take the case of Phil. So, Phil has Chronic Kidney Disease (CKD). Imagine a scenario where his clinician has visibility of all of his questions in advance of his appointment. Phil accesses the educational curriculum before his appointment, and he has it directly on his smartphone. That content helps him learn about topics that are important to his health journey, including mental health, nutrition, aspects of self-care, and how he should take care of himself as someone with CKD. In advance of his appointment, his doctor knows exactly which articles and videos he’s consumed, but deeper than that, he also knows how Phil interacted with the content. Did he have questions on it?
For example, FAQ could exist. FAQs are a good example of a small, but important feature that can influence how someone receives support for their health or life circumstances. It provides in-the-moment guidance, but also encourages information seeking behavior.
To explain this – Think of when someone is not well and stressed. They may know what they should be discussing with their doctor. But when someone like Phil sees how other patients have asked questions that he can relate to, he may realize I need to ask more than I originally thought. Can I work while getting dialysis? What signs and symptoms should I look out, out for? How will I communicate about having CKD to my kids?
M: These are all questions that he might not have thought of at the moment, but when he sees other people asking them. And he realizes he actually needs to have that discussion too, and he needs to know those answers, right?
J: It’s really prompting him to go seek out more information and encouraging him to engage with educational material on a deeper level. And the final piece of that example is what if Phil could share more about his life outside of appointments?
A limitation of modern healthcare is not knowing what’s going on with the patient in their daily lives in, in between appointments, which are, are often months apart. What if Phil could share more about the type of his preferences and other aspects of his daily life that play a role in the type of treatment and mode of self-care that he should consider? So then, when a patient has an appointment, it’s really transformed into a collaboration session.
M: Right? And collaboration sounds time consuming, and expensive in an appointment, I know what an appointment is. Like, I go to my doctor and they just tell me some stuff, ask me some very specific questions and, you know, maybe write me a prescription for me, or not. And then I go. What’s different about collaboration? How do we frame that interaction so that it is more collaborative?
J: One powerful way that a patient and clinician can collaborate together is shared decision making. Shared decision making is when a patient and their clinician work together to determine what treatment options are fit, looking beyond strictly clinical factors. Core to shared decision making is acknowledging differences, differences that exist in values, living conditions, home environments and, and lifestyles between different patients.
As a patient, I may need to keep my job while undergoing treatment, or on the other hand, I may need a flexible schedule so I can take care of my kids. Maybe socially, I value being independent. On the other hand, someone may rely on a caregiver for support. Broad spectrums of preferences exist: I may prefer to avoid needles or keep my six cats or go for a swim. So these are all factors that influence the type of treatment that’s a fit for someone.
As a result of these insights, a clinician can show up for a patient as a partner and help them to understand the care plan that’s the best fit for their unique circumstances. And, importantly, if we look at vulnerable populations – if a patient needs support from a social assistance program, or a counselor, they can make that part of their plan as well. It’s about recognizing individual needs, and then designing a treatment plan that will best support a successful outcome.
M: I think it seems like a good time to ask about what is the benefit to the clinician or coach of using tools like this? I mean, they currently have a way of working and, may not be perfect, but at least it’s getting some stuff done. I mean, what are the main benefits to switching to this more collaborative, shared decision making oriented kind of model in the digital realm?
J: Yeah, there are a lot of benefits to clinicians and coaches. Firstly, it’s helping to make their limited time and appointments more productive and effective because a clinician or coach has access to a rich reservoir of information on their home life, their preferences, questions, they have, their progression towards goal setting and, and more details of their life outside of appointments in advance of the time that they’re meeting together.
This information can include some insights on someone’s psychosocial state, like how confident or supported they feel, but it may also include things that you specifically want to know in your program. Specific programs – clinical or human services – may care more or less about different data on a patient’s life outside of appointments.
There’s evidence that suggests these insights can help clinicians or coaches be maximally impactful in the short amount of time that they have. We recently heard anecdotally from a coach that was using our app, that it saved her 17 hours in meeting time.If we think about how time constrained healthcare and human services sure workforce, this could make a huge impact in fighting burnout among these valuable roles and, and the work that they do.
M: Well, that’s, that, that is all really interesting and such a powerful idea that we can take tech that has largely been used for, you know, throw away stuff or selling people things they don’t need or whatever, and turn it into a powerful tool for transforming our society and hopefully making a more just, more equal society and, increasing access to the kind of care that so many of us just take for granted. So what are the takeaways from this?
J: One takeaway is it’s important to recognize the limitations too. There are risks that technology can also exacerbate inequalities. What if we only create experiences that benefit a particular profile of user and one that is privileged? So if we think about most telemedicine or even prescription delivery services, or who owns an Amazon Echo, these are typically cases that are not designed for traditionally underserved populations. I’ve learned that it’s important to, when trying to design a solution for a group that experiences a health disparity, that you involve them collaboratively in the process and you recognize that they know their lived experiences best.
M: So, what’s next for you?
J: In the near term, we’ve had several exciting new launches over the past few months supporting really unique populations. On one hand, CKD LifePlan is helping patients with chronic kidney disease make more informed, confident and timely treatment decisions. And then we’re also working with our partners Starling Minds to address the burnout crisis among educators and healthcare workers.
I am also personally excited to do some training in UX design, and build my skill set in this area. I’m interested in getting more hands-on in the design process of creating solutions that improve people’s lives myself. I think this will be a new challenge, and one that I’m looking forward to taking on!
M: Wonderful. That is, that is exciting. Well, thanks, thanks for this conversation, Jessica. I really appreciate it’s really interesting to get a glimpse inside your mind and what you’ve been thinking about and where you think the future could take us.
J: Thank you for taking the time.
Connect with Jessica here