The eternal question in healthcare is how to change a patient’s behavior for the better in order to improve outcomes and reduce costs? Patients’ resistance to change is at once bewildering and puzzling. Although patients may recognize they need to lose weight to prevent another heart attack or eat correctly to manage diabetes, few succeed in doing so. What is it in human nature that prevents patients from doing what is necessary to improve their own health and in some cases, save their own lives? Providers, scientists and researchers are continually asking, “What will it take to get patients to change and adopt positive health behaviors?”
To understand that is to dip our toes into the deepest recesses of human psychology. It takes us into the territory of “attribution retraining”, behavioral economics and transtheoretical models of behavior change. The factors at the core of these psychological models reside deep in the human psyche. You don’t have to have a psychology degree to be fascinated by the studies of human behavior and our ability, or willingness, to change. Let’s take a look at some of them.
Fostering wellness to leave illness behind
Today, healthcare is trying to evolve into a system that proactively fosters good health. The goal is to leave in the dust, the old reactive system that treats illness and disease as it occurs. That can improve patient outcomes and reduce costs. However, retooling the system requires the ability to unlock the tangram of human behavior to motivate patients to live healthier lives. Better health is the most powerful way to reduce healthcare costs.
One of the biggest challenges is that the American population is aging, and with that comes a plethora of expensive illnesses and chronic disease. Many of them are caused by individual lifestyle choices and health behaviors. A recent study shows that of the diseases that contribute to the majority of US healthcare costs, which total more than $3 trillion annually:
- 31 percent can be “directly attributed to behaviorally influenced chronic conditions
- 69 percent are “heavily influenced by consumer behaviors”
It’s not just an American problem. The majority of deaths worldwide are due to four diseases:
- Cardiovascular disease
- Type 2 diabetes
- Respiratory diseases
According to the Agency for Healthcare Research and Quality (AHRQ) the “high and growing burden” of these diseases is due to four behaviors:
- Smoking tobacco
- Consumption of alcohol
- Eating highly processed foods
- Physical inactivity
By the way, the AHRQ also says those behaviors lead to disability and premature death. As a result, it is clear that improving lifestyle habits could save patients thousands of dollars in healthcare costs. It could save the healthcare system billions of dollars. That’s rich potential – if only health behaviors could be changed.
Before change comes language
There is a dearth of tools and technologies designed to motivate people to change their behaviors for better health. At the most basic are the treadmills that often serve as clothes hangers in many people’s homes. At the most highly evolved are smart watches, FitBits and innumerable apps for most any exercise an individual would want to pursue. But before change, and use of technology, comes language. What are the words and messages that resonate with individuals to effect change? What cuts through the cacophony of daily information to zero in and hit home?
A study from the University of Illinois at Urbana-Champaign (UIUC) discovered that simple, aligned messages are most effective. When instructions seem to go in one direction, they are easier to remember. They make more sense. For example, telling people to increase the amount of fruits and vegetables they eat and increase exercise is easy to remember because it’s all about “increasing”. However, telling an individual to decrease salt intake and increase exercise is more difficult because “increasing” and “decreasing” seem contradictory. Messages that combine action and inaction make it more difficult comply. Dolores Albarracin, a professor of psychology at UIUC and author of the study, said the most effective messages to improve health behaviors pay attention to two factors:
- The numbers of behaviors addressed
- The way in which the behaviors are combined
Before technology comes psychology
Once the messages are appropriately and effectively crafted, it’s essential to understand and incorporate the psychology of change. Thousands of strategies to change health behaviors have been tried; raising prices on tobacco and alcohol, increasing education, using monetary incentives, developing new school programs and banning soda from school vending machines. New fad diets, paid diets, home exercise equipment and of course advertising promises of being rich, beautiful and thin litter the landscape. However, as the disease statistics show, none of these efforts are substantially reducing the rate of chronic disease and obesity. It’s enough to make scientists, physicians and marketers pull their hair out. The answer as to why Americans find change anathema lies in the psychology of change.
While psychology itself is complex, the psychology behind resistance to change is not, at least according to David Asch. He is a professor of medicine and health care management at The Wharton School, University of Pennsylvania, and co-author of a paper entitled, Behavioral Phenotyping in Health Promotion Embracing or Avoiding Failure. Asch contends that wellness programs make one basic, erroneous assumption; that we are logical beings.
“A lot are designed with the idea that we’re perfectly rational people. That a little bit of feedback — you could lose a few pounds or you should eat a little bit less — is naturally going to fall upon a rational human being who’s going to say, ‘You know, you’re right.’ The trouble is, I don’t necessarily want to get on the scale in the morning and get that feedback. Sometimes that feedback isn’t so helpful. Sometimes it’s a little aversive.”
Shreya Kangovi, professor of medicine at the University of Pennsylvania, senior fellow at the Leonard Davis Institute of Health Economics, co-authored the paper with Asch. He says what is needed to help people improve health behaviors is a concept called “positive affect indication”. It’s the idea that self-affirmation, or being kind to oneself, can help an individual stick with positive behaviors after experiencing a discouraging event, like stepping on the scale. Instead of giving oneself negative messages like “I’m a failure”, it’s more successful to think of other small successes in daily life. Reinforcing oneself is necessary in order to change health behaviors and continue to build self-improvement.
Attribution retraining goes hand-in-hand with positive affect indication. Asch and Kangovi say it teaches people to “view their failures as controllable rather than uncontrollable”. In other words, if the scale doesn’t go the way you like, or you didn’t work out for a week, that’s not a reason to go off the deep end and eat a quart of ice cream. Rather, attribution retraining will lead the individual to think, “That’s ok, it was a bad week. Tomorrow is a great day for a walk”. Asche and Kangovi say these techniques are the best way to “bolster people against the inevitable challenges they’re going to face” in trying to change health behaviors in order to develop healthier lifestyles.
It may be time for a kindler, gentler approach. Boot camp doesn’t work for most people. Kangovi says the majority of people fail to change health behaviors, but it’s not because they don’t care. “We’re learning from our research that the people who fail maybe care too much.” He says if behavioral feedback were kinder and gentler there might be better results.
Other scientists agree. The Economic and Social Research Council in the UK conducted a study in 2006 that studied various types of behavioral change strategies. It found that “the least effective strategies were those that aroused fear or regret in the person attempting to make a change.”
That brings us to behavioral economics. By definition, it is the study of the “effects of psychological, cognitive, emotional, cultural and social factors on the economic decisions of individuals (and institutions)”. It is actually a fascinating science that shows that people are irrational in highly predictable ways.
Behavioral economics is helping to put a fine point on designing wellness programs that might actually work. Asch says, “Some of us respond to different interventions for our irrationality than others. So, it’s two steps removed from the typical program, which is we are all the same, we are all rational, and therefore an education program works. That’s way too simplistic.”
If you ever watched the movie “Analyze This” starring Billy Crystal and Robert DeNiro, you’ll remember Crystal’s character, psychiatrist Ben Sobel, saying repeatedly “It’s a process”. He was right. Change is a process. In fact, it’s the basic tenant of one of the most widely accepted models of behavior change in science; the transtheoretical model of health behavior change (TMM). It’s based on a concept that says that individuals are constantly in one of the five stages of change: precontemplation, contemplation, preparation, action, or maintenance.
Individuals trying to change health behaviors must move through each stage. Different personal change strategies are required for each stage to be completed successfully. If one stage is short-changed or skipped, change cannot be permanently imprinted and setbacks are experienced. TMM provides a clear window of insight into the complexity of the human psyche, the difficulties of change, and the tenacity that is required to make them permanent.
A study in the American Journal of Health Promotion said there is a basic rule of thumb for the at-risk population journey through the stages:
- 40% in precontemplation
- 40% in contemplation
- 20% in preparation
Notice that none of those involve action or maintenance. Maybe it’s because who among us, except for trained experts, understands TMM and that it is at the root of success or failure to change? When we launch on a new exercise or diet plan, do we have the benefit of that knowledge? We argue that no, we do not. It’s one more complex deficit in the web called behavioral change.
The American Academy of Family Physicians (AAFP) calls TMM the “Stages of Change”. It promotes the model to family practitioners as a good way to help patients adopt healthier lifestyle habits. The AAFP believes that TMM can help physicians to match positive health interventions with patients. “By identifying a patient’s position in the change process, physicians can tailor the intervention, usually with skills they already possess. Thus, the focus of the office visit is not to convince the patient to change behavior but to help the patient move along the stages of change.” In other words, using TMM, the physician can reinforce personal choice.
The ability to make our own choices is both the most powerful part of being human and the bane of our existence. Changing the environment may help individuals to change health behaviors. That’s where behavioral science comes into play. The environment always impacts our choices whether we know it or not. That’s what mood lighting, aromatherapy in stores, and packaging design is all about. How many times have you gone into the store to buy the ingredients for a salad only to met with aromas of baking bread from the bakery? It can easily sway your buying decisions.
Environment has the power to alter human behavior. Google is using this to guide employees to make healthier choices. Corporate cafeterias are designed to encourage healthier eating. The healthiest choices are front and center in displays. Green labeled foods are the healthiest. Water is stocked in the refrigerators at eye level. Cynics will say it’s just one more effort by Google to make its employees work harder. That may be true, but it’s also true that it has created an environment where eating healthier is easier. A cafeteria that defaults for healthy food makes the high-fat, high-salt food harder to choose.
Can technology tip the stages of change?
In a word, no. As we have seen, individuals must choose to change health behaviors. Once they do, they must successfully complete each stage of change if it is to be permanent. However, technology can support that journey. An article in the Harvard Public Health Review said, “Realizing and addressing the fact that so many of the outcomes that lie inside of healthcare are rooted in factors that lie outside of health care is critical to improving health.” Digital devices, apps and personalized feedback can help some individuals to control external factors. If they do, then technology begins to build a bridge between the desire to build healthier behaviors and actually accomplishing that goal.
Granted, there are those who are fully engaged in personal health and who use technology daily. The “quantified self” is a well-recognized phenomenon that has now become part of our daily social strata. Those are the individuals who want to live as long as possible. Consequently, they regularly (perhaps obsessively) measure, document and track the food they consume, the steps they walk, their heart rate and even the temperature of their skin. However, these are not the high-risk, non-compliant individuals suffering high rates of chronic disease. So once again the question becomes, can technology help those who need to change health behaviors the most?
Technology isn’t the “be all and end all” of behavioral change, it’s a support system. David Asch said, “I’m very optimistic about technology, but I want to see it as an enabler. It’s not a leader. Fitbits don’t make you walk more, but they can enable a lot of other strategies.”
Technology combined with monetary incentives is a power couple for some individuals. A clinical trial conducted at Penn Medicine studied how to get patients with heart disease engaged in regular physical activity. It contradicts other studies that said that fear-based programs are less effective. Researchers said they found that wearable fitness devices alone were not enough to motivate high-risk cardiac patients to exercise.
The Penn Medicine trial combined remote home monitoring fitness devices, personalized step goals in a walking program, and $14 a week. Two dollars were taken away for each day the step goals were not met. The results of the six-month clinical trial found that patients in the paid group walked about 100 more miles than patients in the non-paid control group.
Technology that incorporates a sense of community is sometimes more successful in helping people adopt healthier behaviors. It goes back to a core characteristic of human beings; we are social “animals”. In fact, a study in the Journal of Health Communication found that socialization activities directly impacted health literacy. “Low health literacy was associated with greater loneliness, engaging in fewer social activities, and having fewer social contacts.” So, while those engaged in healthy lifestyles may do well with a smart watch or FitBit, others may need a sense of community to start exercising.
Fortunately, there are many apps on the market that offer an interactive community experience when trying to change health behaviors in the pursuit of better health. A few of them, (not meant to be endorsements) include:
- Fitocracy that offers interactive coaching and a community of support
- ACTIVEx customizes workout plans for individuals at any level and offers a community of support
- DietBet allows users to receive and send motivational messages
There are hundreds of apps and these are just a few examples, but they illustrate the point. Humans are not solitary beings. When community compliments technology the health engagement net is spread just a bit wider. That may support a change in health behavior.
The American population is aging. Chronic disease is increasing. We all need to learn, relearn and/or maintain healthy behaviors. It behooves all of us; physicians, friends, family, and social support programs to educate and support those who need to change unhealthy behaviors. “It takes a village” may be cringe-worthy to some, but that’s the bottom line. The human psyche is a byzantine place, and when it comes to changing behaviors it looks like none of us can do it successfully on our own. It is time for the healthcare system to change to proactively supporting good health. It’s going to take all of us to further the relentless pursuit of that goal.