Applying Behavioral Research for the Health of the Self
Insights from the U.K. Behavioural Insights Team (BIT) at the NEJM Catalyst were put forth in October to help shape public policy toward health care by using evidenced-based behavioral research to determine the best way to encourage healthy habits among the public.
The NEJM Catalyst publishes insights and innovations to improve health care delivery, but the insights, with their focus on how and how not to encourage good habits, are useful for all of us. End-of-year self-improvement initiatives are nothing new; here we attempt to adapt some wider behavioral findings to make them more effective.
How do we best use this behavioral research on ourselves? What works and what doesn’t? The basic summation of the authors’ research-backed approach to behavioral change is this: In order to encourage a behavior, make it Easy, Attractive, Social, and Timely (EAST).
The more effort that a behavior requires, the less likely someone will be to do it. This is obvious, but what’s less so is how behavioral science research shows that even small amounts of effort can have a disproportionately large effect on outcomes. This works both to deter and to encourage. Small negative influences matter. At the same time, small positive steps are often easy—and very worth taking.
For example, a U.K. law that made it slightly more difficult to buy painkillers in large quantities (and to release them from their packaging quickly) was found to have prevented around 800 suicides over 11 years. The slight increase in effort required was enough to save lives.
Big changes that are nevertheless easy to implement (driving directly to the gym after work) aren’t always necessary. Small inconveniences can also stack the deck toward fitness: purposely park on the far end of the megastore lot; forgo the elevator; walk to lunch. When set in motion properly, minor changes that require increases in caloric expenditure don’t deter active behavior; they deter sedentarism. These changes are tolerable and can have big gains over time.
The same goes for caloric intake: only cook the pasta you’ll need for one meal, so overeating seconds or thirds simply isn’t an option; purchase smaller plates so piling on is less easy; skip the dinner rolls before the meal to avoid the empty carbs. Remember, by reducing caloric intake by just 10 calories a day—that’s less than a single LifeSaver candy—you will lose over one pound of bodyweight per year (there are 3,500 calories per pound). That’s enough to at least stave off the annual weight gain that so readily accompanies us as we age.
People are exposed to a vast amount of information every day. We in turn develop strategies for filtering out most of this and focusing only on a few pieces. Therefore, information is only likely to influence behavior if it’s delivered in a way that attracts attention effectively.
Because one in 10 hospital appointments is missed (according to U.K. data), reminding patients by text message is widespread. But the BIT team points out that little thought has been given to the wording of these messages. BIT randomly allocated patients to receive several different reminder messages, and found that the best-performing message stated the cost of a missed appointment to the National Health Service. It reduced no-shows by almost 25%.
The lesson for us? Take time to brainstorm your specific reasons for wanting to eat healthier, wake up earlier, exercise more, or other goal. After the list is compiled, winnow it down to the top five reasons, and post the list in a position of prominence in your home, perhaps in several places: on the fridge, by the bed, or next to your running shoes. The attractiveness of these core priorities can help bring you back to a place where your desired habit has poignant emotional meaning, and is not simply a lofty abstraction.
Individuals are strongly influenced by what they see others do—or even by what they are told others do in the same situation.
In another randomized trial led by BIT and Public Health England, this idea was applied in an effort to reduce the use of antibiotics in primary care. (As we explored in the last issue, microbial resistance to antibiotics is of growing concern.)
The trial used online prescribing data to identify the primary care practices that were prescribing antibiotics at a higher rate than other practices in the local area. The practices were politely notified, and reduced their collective prescription rate by 3.3%, which sounds paltry until you realize that across 800 over-prescribing practices, this resulted in an estimated 73,406 fewer doses over six months at a savings of £92,356 in direct prescription costs. The authors note, “As a point of comparison, in the same year, the National Health Service spent £23m to [monetarily] incentivize general practitioners to achieve...a 1% reduction in their prescribing rate.”
Apps like MyFitnessPal, Runtastic and others encourage users to share their goals and achievements in the online community for precisely the same reason. The social accountability is in itself powerful, but the establishment within the community of what is normative can provide people with even more motivation to perform up to a certain level. This is, in a way, a new spin on the age-old practice of mailing a letter to all of your friends and family members announcing that you are, say, quitting smoking. The thought of any social encounter going forward during which you are seen ingesting tobacco, the thinking goes, is sufficiently negative as to cause deterrence.
Behavioral research shows that the likelihood that someone will accept an offer can vary greatly depending on when it’s offered. Certain moments can disrupt existing patterns of behavior and provide the opportunity for change.
In one study, the experience of having even minor surgery was shown to increase the likelihood of quitting smoking by nearly 30%, and receiving a short smoking cessation intervention at that time increased this effect even further.
Look for opportunities in your own life when your susceptibility to change in pursuit of a desired outcome may be high. For example, think of how common a practice it is for brides and grooms to try and shed extra pounds in the approach to their wedding day. But it’s entirely possible to force change without it revolving around a (hopefully) once-in-a-lifetime event. Sign up for a road race that’s still months away, plot out a sensible training regimen, and focus on the necessity of raceday preparedness in order to maximize pleasure and reduce injury risk. This is the kind of high-susceptibility time period that can keep you on track.
After the race, think of all you’ve gained that you now don’t wish to lose. As 79-year-old masters champion Imme Dyson once put it, “The first two weeks that I ran I was hurting, truly hurting…Now I might have some pains and aches, but I never have to go through that again.” That knowledge motivates one to keep going. Why put your body back through such an unpleasant, detrained phase once you’re past it? Better still: sign up for another race.
The BIT authors argue that EAST principles “should be part of the basic approach for anyone working in health care policy and service design.” Here the case is made that EAST principles can and should be kept close at hand when designing any individual life-improving regimen, to maximize the odds that good habits will take hold for the long term. It has certainly worked for Imme Dyson.