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:
• 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.
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.
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.
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 20% off the list price of my book)