by Carolyn Thomas ♥ @HeartSisters
In classic scientific understatement, U.K. researchers Drs. Michael Kelly and Mary Barker observed that “most efforts to change health behaviours have had limited success.”(1)
No kidding. Right now, even as you read this, academic researchers all over the globe are applying for (and getting) grant funding to embark on yet another new study examining smokers who don’t quit, couch potatoes who don’t get off the couch, or overweight people who don’t lose weight. I can’t be 100% certain, of course, but I’m betting my next squirt of nitro spray that these studies will no doubt conclude that, yes indeed, those people do need to change their behaviour, and “further study is required”.
You would think that having had a cardiac diagnosis would be all the motivation anybody would ever need to quit smoking, or join a gym, or say NO to Tim Hortons maple dips. And you might also think that freshly diagnosed heart patients would listen carefully to their doctors’ advice on changing unhealthy behaviours. For some people, a wake-up call like a serious cardiac event is indeed a powerful motivator to change.
Yet behaviour scientists continue to report that most efforts to convince heart patients to embrace cardioprotective lifestyle changes are generally pretty dismal.(2)
In the PURE study (Teo et al, JAMA, 2013), for example, researchers followed over 7,500 heart attack survivors in 17 countries. They found that:
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• 48% of smokers continued to smoke
• 65% did not exercise
• over 60% did not improve their diet
• 14% had adopted not one single lifestyle improvement
So it’s safe to conclude that, generally, most behaviour change advice does not seem to be working. In their study published in the journal, Public Health, Kelly and Barker bluntly conclude that “the extensive body of evidence of how to bring about behaviour change is consistently ignored.”
Our healthcare professionals want us to be healthier by making healthier lifestyle choices. Most experts agree that long-lasting change is most likely when it’s self-motivated. Yet in some jurisdictions, hospital and clinician payments are tied to being able to convince patients to “do what I tell you”.
In fact, Kelly and Barker’s study lists six common errors that get in the way of even the most well-meaning health-related behaviour change attempts:
Error #1. “It is just common sense!”
The advice-giver’s argument here is that it’s obvious what needs to be done, so just get on with it – especially when the change advice comes from somebody who is already living an exemplary life. (See also: Please! No more bragging about mountain climbing!) But if healthier behaviour choices were only about making simple changes, then we’d all be making them already. Common sense, as Kelly and Barker tell us, has led repeatedly to ineffective interventions. Consider eminently common-sensical – yet dismally failed – public health campaigns like Just Say No to Drugs.
Error #2. “It’s all about getting the message across”
This approach argues that if we could only come up with the correct message with just the right words that people could clearly understand, then everybody would change when they hear that brilliant message. It’s what scientists call the “stimulus-response” model of behaviour (I hear the message, and then I will immediately respond to it). Might work well with lab rats, but not so much with humans. . . And when messages do work (as they have done during massive national quit-smoking public health campaigns, for example), they are part of a sophisticated multi-level strategy, just one part of broad, many-pronged consistent policy messages over many years.
Error #3. “Knowledge and information drive behaviour”
Behavioural scientists warn us of the folly in believing that information from an expert source is a driver of behaviour change. This belief borrows from traditional medical hierarchy models of the doctor–patient relationship, namely that patients have an information deficit and doctors will remedy this deficiency. Many of us, for example, are permanently dieting in order to lose weight. Personally, I’ve been on a diet (or going off my diet, or going back on a diet) since age 13. I don’t need more knowledge about losing weight. I know how to lose weight (because I’ve done so much of it over my entire life!) But most diets fail, not because people haven’t yet bought Dr. Mark Hyman’s latest diet book but because, as Kelly and Barker explain, knowledge and information alone do not drive behaviour.
If they did, mirrors and bathroom scales would be all we need.
Giving people information does not make them change. For example, when Kelly and Barker studied younger women, they were told consistently by the women that it’s not that they don’t know that they and their families should be eating a healthy diet with more fruit and vegetables. What they do tend to say is that “many other things in life get in the way of doing this.”
NOTE FROM CAROLYN: Read “Women’s Heart Disease: an Awareness Campaign Fail?“ for a shocking example of how years of giving important information to women about heart disease has not only failed to raise awareness, but women’s awareness has actually declined over the past decade.
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Error #4: “People act rationally”
Error #5: “People act irrationally”
Here’s a paradox: it’s not true that we always act rationally, but the opposite is not true either. We’re not always irrational. Kelly and Barker warn that it’s arrogant to assume people consume alcohol, chocolate, or junk food because they are simply behaving stupidly. They also cite research on women living in poverty who have still somehow found money to buy their cigarettes.(3) When asked why, the women said that sitting down for a smoke was the one opportunity in the day they had a chance to do something completely for themselves. In this context, smoking was not an irrational thing to do. Humans know what they’re doing, and they can account for their choices in meaningful ways which make complete sense to them – even when they make little sense to others.
Error #6: It is possible to predict accurately
The Public Health paper suggests that public health policy is often driven by a naïve desire to predict things. (“If we can raise their awareness, people will change for the better”) rather than to understand what led to the things happening in the first place.
Prediction seems simple, and it is far less effective and accurate than unraveling the cause. It’s still difficult to say with any certainty how individual people will behave in any given situation. Kelly and Barker point out the big differences between individual behavior choices and group behaviour patterns in society. While we can describe patterns in great detail, they say, we don’t have “sharp-edged tools with which to tackle health inequalities, the obesity epidemic or rising alcohol consumption rates.” Meanwhile, policy makers continue to fall back on platitudes about “getting people to change their behaviour.”
So if these six common mistakes make motivating others largely ineffective, what might work instead?
Some suggestions borrowed from behavioural science include the following:
1. The nudge: Many of our behaviours are driven by automatic responses requiring little brain engagement, often triggered by our environment (think of the irresistible impulse to buy a chocolate bar when it’s staring right at you at your grocery checkout when you’re on your way home for dinner). The ‘nudge’ refers to making small changes in the physical or social environment that make specific behaviours more likely – Kelly and Barker mention, for example, placing fresh fruit and vegetables at the front of a food display as a kind of nudge that makes healthier food choices more likely. One of my own longterm nudges has been to get my walking shoes/socks ready the night before and place them right by the front door.
2. Evolution of social practice: When my Dad decided to quit smoking in 1951, his friends immediately asked him if he were sick. In that era, only a weak or sickly man would not be a smoker. Real men smoked, and glamorous women smoked. It was a socially accepted practice to start the morning off with a cigarette and a cup of coffee, and keep it up all day long if possible. My parents, like all of their friends, kept a cigarette box, a lighter and ashtrays in the living room for visiting company. The only way that this golden age of tobacco acceptance was broken and changed, according to Kelly and Barker, was when smoking stopped being primarily defined as a glamorous or manly social practice, and became defined as a socially undesirable health problem.
But it took decades for this to happen. The significant decline in smoking rates in my lifetime did not change just because scientific evidence kept saying that smoking was harmful. If that had been true, the tobacco epidemic would have been stopped in its tracks in the early 1950s when my Dad decided to quit. But the social practice had to change first: the tobacco industry and its advertisers were confronted head on; people were helped to manage their addiction; tobacco became very expensive. Behaviour change was involved, but only as one part of a multi-part approach to the issue, and as Kelly and Barker claim:“we will need similarly comprehensive and robust approaches to deal with obesity, alcohol misuse and the consequences of physical inactivity, not facile and simplistic platitudes.”
3. Approach goals, not avoidance goals: The most effective goals are ones that move you toward a particular objective, rather than away from something you’re trying to avoid. As I wrote here, an avoidance goal (“Do this so you won’t get sick”) is far less effective than an approach goal (“Do this so you’ll feel great!) For example, I could decide to head out in the sunshine today for a brisk walk to help me ward off another heart attack (which is an avoidance goal) or I go for a walk to enjoy the beautiful breezes off the ocean (an approach goal).
Behavioural scientists tell us that framing any goal with an approach message is almost always more successful than framing it as an avoidance message.(4) But when we pursue the avoidance goals recommended by our physicians (“I’m changing this to avoid something bad that may or may not happen in the future!”), we are far more likely to experience:
- less satisfaction with progress
- more negative feelings about progress
- decreased sense of personal control
- less satisfaction with our quality of life
- less trust in the belief that we can achieve goals
Two terrific examples of approach goals that are working are Walk With a Doc (a now-international program started by Ohio cardiologist Dr. David Sabgir that recruits physicians who volunteer to lead local walks as a way to encourage communities to become more active) and Heart to Start (a free 8-week Oregon-based program that includes training plans, health advice, weekly group workouts and competitive 5k/10k events under the leadership of cardiologist Dr. James Beckerman – who then wrote the book about his program!) Both programs offer the additional appeal of group community support.
And both of these physicians aren’t simply telling their patients to make healthy lifestyle choices, but they are – quite literally – getting out there with patients and walking the talk, too.
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And for healthcare professionals who are sincerely interested in learning more about the frustrating mysteries of motivating behaviour change, you should look no further than the profoundly wise concept of Minimally Disruptive Medicine as described by Mayo Clinic’s Dr. Victor Montori (author of the equally profound little book “Why We Revolt“). Dr. Montori understands what he and his team call the “burden of treatment” faced by those living with chronic illness in a way that few other physicians get. I wrote more on his important work here, here and here.
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Q: Can you think of a time when you were personally motivated by another person to change an unhealthy behaviour?
1. Michael P. Kelly, Mary Barker. “Why is changing health-related behaviour so difficult?” Public Health, Vol: 136, 2016. 109-16
2. , J et al. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences: (2012) 67B (3): 279–288 October 9, 2011.
3. H. Graham. “When life’s a drag: women, smoking and disadvantage.” (1st ed.), HMSO, London (1993), p. 1993.
(4) Elliot, A. J. & Sheldon, K. M. (1997). Avoidance achievement motivation: A personal goals analysis. Journal of Personality and Social Psychology, 73, 171-185.
NOTE FROM CAROLYN: I wrote more about how heart patients respond to change in my book, “A Woman’s Guide to Living with Heart Disease” , published by Johns Hopkins University Press. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher (use their code HTWN to save 30% off the list price of my book)
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See also:
Please! No more bragging about mountain climbing!
Why don’t we listen to doctors’ heart-healthy advice?
Non-inspirational advice for heart patients
Heart Sisters 
Hi Carolyn,
Thanks a lot for sharing your thoughts on this. After reading the blog, this now become one of my favorite blogs. People must know. Only because of this, most diseases will decrease.
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I’m guilty as charged – can’t find my “won’t-power” regarding my health habits. If it weren’t for my dog Freddie I probably wouldn’t walk. For me fear is my biggest motivator. But once that fear has passed, I revert to old habits and routines.
Since I’m not an “anxious-type” to begin with I am not easily scared into right-behavior. I’ve always wondered if people who adhered to healthy life-style weren’t farther on the anxiety spectrum than I am.
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Thank goodness you have Freddie, Judy-Judith!
That’s an interesting point you raise (are those who are more likely to follow those healthy-living directions also more likely to have generally anxious tendencies?)
This question reminded me of some of the “Quantified Self” people I’ve had the opportunity to meet/interview (Quantified Selfers are those who track (and worse, SHARE!) every daily health indicator that’s remotely trackable – weight, diet, steps, sex life, stress and my favourite – one guy who famously spent decades tracking his computer keystrokes!) They even have national conferences where they show slide presentations to other Quantified Selfers with all the details!
I can’t say for sure, of course, but I’m guessing that these people are more likely to accurately follow ALL doctor’s orders because they’re already obsessing about self-tracking.
Doesn’t mean that they’re necessarily anxious people, just means that I never ever want to be stuck sitting next to one of them at a dinner party…
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Carolyn — thanks for this timely column. My day job is training health practitioners on how to interact with patients with serious illness. Motivation for change is also applicable to practitioners who are marinated in an environment that reinforces this idea that they are the sole expert in the room and that their job is to impart their expertise. Helping people change is a hard nut to crack at every level.
In my own life, now 3 years post heart attack and deep in the weeds of working on my own health behaviors, I see how much energy it takes to change daily habits. I recently realized as I was driving uphill and had to let off the gas and the car immediately slowed that this was similar to changing my behavior. At this point in time, after 50 years of one set of habits, I have to apply “gas” (energy) to making change and when I run out of “gas”, things immediately begin slipping away.
So, one thing I am thinking about for myself is how to keep enough energy in the tank and to prioritize it to keep my health goals foremost. They are easily lost in the call from others (work, family, etc.) for that limited energy.
Taryn
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So true, Taryn. It takes a lot of energy for a healthy person to succeed at changing behaviours, never mind somebody with limited energy due to a chronic illness. Running out of gas is a good analogy…
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Carolyn, I have to tell you that one benefit of reading your blog is that I’ve ended up with so much MORE reading material from the book links you give. I’ve placed so many of those books on interlibrary loan because I like to research these things and I’m also trying to develop a bibliography of books to recommend to my cardiac support group. Time to add another — the Why We Revolt book, sounds so interesting!
Unfortunately the one I have recently requested (Sleep, Interrupted by Dr. Steven Park, which you recently recommended in a comment on another post) won’t arrive in time for me to read it before getting my Cpap machine — my home study showed I have severe sleep apnea and they want me to start on the machine right away. I so don’t want to sleep with a machine and I had hoped to read that book before the diagnosis came back. 8^( But I’ll read it anyway when I get it, hopefully in time for the follow-up appointment they do at least 30 days after starting treatment.
Thank you so much for doing so much research, filling us in on relevant information, and letting us know about all these great books!
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Hi Meghan – I think you’ll really enjoy reading Why We Revolt – it’s very different than any other physician’s book I’ve ever read! Your recent confirmation of “severe sleep apnea” is NOT what you wanted to hear – for some potential help in adjusting, you might be interested in this 1-hr interview on Dr. Park’s website, “10 Tips for CPAP Success” while you’re waiting for his book to arrive. His guest calls the CPAP machine “a very simple concept to understand, but not to manage!”
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Hi Carolyn
Just to say thank you for your comment when I wrote how alone I felt after my heart attack and stent placement.
Due to your blog when I had a heart rate of 126 crossing the road and managed to stagger home and it didn’t slow after the nitro, I went to hospital. This was when I experienced exemplary emergency care, was admitted and eventually saw a cardiologist after 2 days.
Then I received the kind of care you write about when women present symptoms to some doctors. Outside my room the cardiologist announced to his retinue that I was an “elderly woman with a panic attack”. (Hmm, I didn’t know 64 was that elderly). He walked in, told me he was upping the beta blocker by 50% and prescribing yet another daily pill to dilate my arteries….. he totally ignored my comments about the symptoms that I had been experiencing over the three days and sent me home. He had not seen any notes and did not know I had had an heart attack and a stent fitted. Told him I wouldn’t be taking the increased dosage or the new pill. He flounced out.
One of the cardiac nurses took pity on me and came back to explain it would be a very good idea to collect the meds (so I could be discharged) and then go straight to my own primary care doctor for a “discussion”. Upshot: primary care doc actually reduced the beta blocker and agreed I didn’t need the extra pill but to take my usual aspirin, blood thinners, blood pressure tablet and statin.
I feel better than I have for a long time and a lot less anxious; he also sees me every three weeks as blood pressure is low and heart rate high. I feel involved in my own care.
Without your blog, I would not have argued and just taken the pills and done as I was told. No doubt I would have felt even more chemically coshed than I had.
Thank you, your blog is literally a life changer.
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Thanks for your kind words, Lindsay. Glad to hear that you have such a good working relationship with your own doctor. It’s very frustrating to hear dueling diagnoses from different docs. That hospital cardiologist was a good example of how NOT to do shared decision-making… Best of luck to you…
PS Since when is 64 “elderly”? You can’t even get a seniors’ discount at the Thrift Shop under 65!
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I should have added I started cardiac rehab 8 weeks after my heart attack. As I was the child who wrote her own notes to avoid games and PE at school you can imagine how keen I was to get started… There is no doubt it pays off and I now go twice a week to the local sports centre for an hour of exercise and gym time with a cardiac rehab instructor.
I am in a class of 30. The instructor is not a cardiac nurse and I often wonder without the cardiac team doing the first 8 sessions whether I would have had the confidence to actually do any exercise. A medical friend told me that often heart patients think of themselves as having bodies like glass – too delicate to do anything with.
I walk on the other days of the week and found it easier to give myself time rather than distance goals. I still don’t enjoy it really but I feel a lot fitter. I felt very self conscious to start with but the others are supportive and all have a story to tell. There are few women but I am put to shame in my old T shirt and leggings by the lady who turns up every week wearing a waistcoat, posh blouse and trouser suit, freshly permed and set hair and full make up. Her only concession to sportswear is a pair of canvas shoes. She told me she had been exercising for nearly ten years and thought it had kept her going. She’s had a heart attack, stent and bypass over the years and is 84…..
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I think your friend is right – not too many decades ago, people with heart attacks used to spend a full month recuperating in the hospital on complete bedrest! No wonder they thought they were fragile! And now if we have a twinge or pain during any type of exertion, it can be frightening! That’s hilarious about your exercise buddy in the posh outfit and makeup. Good for you for continuing to show up at your gym classes!
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Hi Carolyn,
I think that the number one reason people have the problems is the wait period from the time they are treated to the time they enter into rehab.
I had been in my hospitals maintenance program from the time I finished rehab until I was stopped last August. There was a strong possibility that I wouldn’t be allowed to return. But I found out Friday why so many people aren’t motivated to exercise and change there habits. There is a three months waiting period before you are allowed to do exercises that involve the chest region. It doesn’t matter if you had a procedure that entailed open heart, implanted devise, or the placement of a stent the heart needs three months to adapt to the change as not to cause damage.
During this time they get to become complacent as to if this is really needed. Doctor send us home to rest and heal but they don’t tell the patient that even the place of a stent takes two to three years to heal. That placing it doesn’t stop your problem or that the things you do can dislodge them. They don’t tell the patient the blow they took to the heart effects what their life will be or that from this point it is a struggle to maintain any form of normal life. Nor do they tell them the importance of rehab, not just for the exercise but the dietary nutritional information that is also given. Then with people like me who had moved on to the maintenance phase that I would move backwards with every event I have.
The episodes I was having that now has me with an ICD changed a lot of things. My EF drop from 40 to 30 changed a lot of how my life goes. I know that I’ve always had a reserved EF which means it has been higher then I have functioning heart muscles. They have been worried that I would have another silent AMI. I feel sometimes like a guinea pig because there is no one like me. Normal ICD implant are set to place and when the heart stops it delivers a shock. I am not being paced and people don’t get it, mine is set to perform CPR. It is to weak to be paced, when my heart quivers and not beat it will pace me until it kicks in, if it doesn’t it will deliver the shock after 5 minutes. I also take my nitro at that time.
The first thing any heart patient needs to do is read up on their condition then ask questions. I found that doctors don’t say because most patients don’t want to know. The want you to fix them and go away, then they chase after anything that says it’s a cure.
Take care,
Robin
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Hello Robin – After three months, it wouldn’t be surprising for heart patients to feel that if they’re managing okay even without going to cardiac rehab, then why go? Speaking of three months, my understanding is that it’s NOT in fact true that stent patients must wait three months before starting cardiac rehab. I wanted to mention it because I wouldn’t want readers to believe something they read here that may not in fact be true for them.
Supervised rehab programs are modified to suit each individual patient. Every patient is completely different and programs are arranged to suit those differences and abilities. Some people living with heart failure for example must be supervised by a cardiologist during rehab classes; others can be safely supervised by a cardiac nurse or trained kinesiologist. Patients with more serious issues like you might have to wait longer before starting, others wait far shorter – often starting while still in the hospital before even going home.
We had a man in our cardiac rehab class, for example, who was unable to do any upper body exercises at all, only able to walk on the treadmill at its slowest possible setting at first, and that was just fine. At least he was doing something! There is no “one-size-fits-all” program. In fact, a number of studies now recommend starting cardiac rehab as little as one week post-hospital discharge for heart attack and stent patients. For evidence behind this practice, read: “Why Your Heart Needs Work, Not Rest After a Heart Attack”
I agree with you – all heart patients need to become what I call the “world experts” in their own diagnosis.
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To facilitate behavior change the systems need to be more flexible!!! I had a heart attack 4/3/16 and went back to work 4/20/16, and was assigned to cardio rehab three times a week. I tried the 6:30 am class and overslept twice. The third time I was running 20 minutes late but was on my way. I had a choice of being late for rehab or leaving a client having a mental health crisis to figure it out on their own. As I pulled into the parking lot of rehab, I received a call from them dismissing me from the rehab program. End of discussion.
REALLY? I have to do client centered rehab for mental health but they can’t do client centered rehab for a heart attack!
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Matching up a patient’s realistic availability to attend with the cardiac rehab program requirements can be tough to do. (I have to say that I’m envious that you even HAD a 6:30 a.m. option – most rehab programs don’t, which means they can’t accommodate working people at all as your program does. I had to take time off work three mornings a week for mine). Sounds like your rehab program had its own ‘three strikes’ policy…
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