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Thoughts after a panel on behavior change

A bit ago, I attended an outstanding panel discussion of behavior change in the health care space, called “Patient Engagement: Whose Responsibility is it Anyways??” I took notes on general themes through the talk. Some of what was said seemed persuasive, some didn’t, and some left me really wishing I could interject. So here’s my chance.

I’ve organized the panel into general subject areas, with panelist comments in bold and my thoughts below in plaintext. As a disclaimer, I’m offering these thoughts as an interested observer with a stake in learning how to drive behavior change. I don’t claim more expertise than that; but hopefully this will at least be of interest and will point out some relevant resources and literatures.

1. What are the barriers to patient engagement?

The tools to help people commit need to be fun, gamified, or otherwise engaging.
I thought of HopeLab, based in California, and a series of games they developed called “Re-Mission,” designed to help young cancer patients engage with their treatment. Really worth checking out!

More broadly, and especially for adults, I’m a bit skeptical of gamification—both whether it’s possible in all circumstances, and whether it engages the parts of people we really want to engage. Section 5 (“General thoughts”) touches on this.

“It’s not to fair to blame the patients”: they have good goals, but “life gets in the way.” Anyone can adhere to a treatment in a structured setting; the real question is how to break cycles and routines.
Sounds true! I wrote this down mostly because of how true it is in my own experience (with meditating, lifting weights, moving off nocturnality…).

“No one wants to feel like a patient”—“human engagement” is key.
I certainly agreed with this point. There’s a broader question of approach: about really taking interest in people themselves, rather than just in their outcomes. The difference has to do with the difference between orientation toward self (“I’ve managed to keep this patient taking his medicine, so I’ve done my job”) and toward other (“How is this person doing?”), which is a very important but very slippery distinction in any setting.

Healthcare is “not a very pleasant experience.”
I agree, although I’m not sure that the panelists’ enthusiasm for “gamifying” healthcare, etc., could resolve the fundamental scariness of the experience. They asked (I’m paraphrasing) why going to the doctor couldn’t be like going to the movies. My answer would be that the healthcare system involves threats to one’s health and even one’s life, as well as huge financial cost.

I think working to sugarcoat these truly scary issues is probably not the right approach, at least for adults. However, genuine care and human engagement, and some attention to details like how the facilities are kept up, would make me more likely to engage. The panelists mentioned making better use of modern technology, and I’m sure that makes sense as well—but only to make healthcare more efficient, not “fun.”

2. How do we construct incentives?

“Incentives work”—but how to sustain engagement after first involvement?
I’m not sure “incentives work,” necessarily. A lot of the time, a flat-out bribe will be incentivizing the wrong thing—like filling out a form rather than doing the underlying behavior the form is supposed to capture. I remember my public library offering a prize for every book we read during the summer, so I read ten of the library’s shortest books at lightning speed.

Find intrinsic motivation: “What do you actually want?”
An interesting question. Someone who wants “to lose fifty pounds” might actually want his kids to be proud of him, to paraphrase the example given. I think tools that elicit what people are truly interested in are very promising in this area. We’re trying this for meditation with our “meditation portrait” feature, so far with mixed results.

Not “let’s try to get people to do what they don’t want to do,” but “let’s try to get people to do what they want.”
This does sound like the right approach—and making change feel like something we “have to” do is a major cause of failure, as Nir Eyal argues in a recent and, I think, persuasive article.

One thing to note: “Getting people to do what they want” should be a trivial problem! It’s not, so why not? This gets to the (unstated) distinction between short- and long-term goals, or even between the goals valued by the multiple “selves” that drive our behavior. These distinctions didn’t come up during the panel, but there’s a whole literature around the way our goals shift with time and other factors, which I believe is fundamental to this topic. Some basic terms in the literature include: time-inconsistency, hyperbolic discounting, bounded rationality, behavioral economics.

“The environment has to change, or behavior can’t change.”
The panelist cited a study showing this. I agree environment is extremely important, but I don’t think this ought to be stated so strongly. Otherwise you admit that, for example, working with prison populations is “doomed” on some level.

3. Where’s the money going to come from?

This question is “a big barrier to innovation”—what are the revenue models? “Nobody has nailed the business model” yet—that’s the real opportunity for innovation.
I agree. From our experience in the space, “corporate wellness” seems like the cash cow, but that’s as vague as it sounds.

Broadly, people may not be willing to pay to accomplish long-term goals—after all, we’re often barely willing to act to accomplish them, which is much of the reason behavioral support tools exist in the first place. So the problem of getting people to pay for behavioral supports is an extension of our startlingly low valuation of long-term goals in the first place. Solving one problem should solve the other.

As a separate note, I do think it’s fine if the space isn’t a giant moneymaker—but paying the salaries of the people who attempt to innovate in it would be a great start.

Who pays for compliance solutions? “Consumers aren’t paying money for their health trackers.”
Broadly, this makes some sense, since health trackers aren’t much of a value add. People will pay money for a gym membership, since they get access to concrete services as a result. So perhaps a health tracker needs to do more than simply encourage someone to be disciplined and store analytics.

Does corporate wellness actually carry an ROI? To really drive business, corporate wellness companies need to be “measuring hard outcomes”—they all promise “your overall health costs will go down,” but “where’s the data?” No one has it yet, since the field is relatively new.
This point felt extremely well-made. It’s a chicken-and-egg problem to some extent, and the first actors to solve it will probably be the ones to really take off in the space.

4. How to change behavior?

Employ very tiny steps and start there.
I’ve heard this advice before, and have recently used it. For example, if I’m trying to meditate in the mornings, I can at least set my alarm for 8:00 AM. Whether or not I go back to sleep, it’s a start. I believe in this, although even sticking with these minute steps takes some discipline.

“Help people see that they’re making progress” (“close the feedback loop”).
This sounds great, but behavior change is difficult in most cases because this can’t be done effectively. Smoking may shorten your lifespan on average, but people still do it because it gives an immediate reward in exchange for what feel like far-future, probabilistic costs. If smoking killed you that day, no one would do it in the first place.

For me, “closing the feedback loop” on meditation would have to be a very powerful experience directly because of my practice. A printout on my self-reported average stress levels over time would likely find its way into the “useful trivia” bin relative to the immediate reward of watching YouTube videos.

Social support—“find a [meditation, running, not-smoking, etc.] buddy,” and have this friend text you to do it at the assigned time.
I think responsibility to others is possibly the most powerful driver of behavior change. I volunteer for a meditation event on some Sundays, and I’m required to wake up at 7:45 to unlock the doors at 8:30. It’s extremely unpleasant, and there’s absolutely no way I could do it on my own initiative; but since I know I’ve promised others I’ll do it—and that I’ll hear from them if I don’t—I’m able to make it work.

5. General thoughts and conclusions

Broadly, I have a hunch that effective behavior change has to rely on our “better angels”: Not our desire for money, our need to be constantly entertained, or our fear of consequences, but our sense of responsibility to others, our aspiration to live a better life, and so on. This seems our best hope for behavior change that is reliable, not coercive, and free of odd side effects.

So if I had to bet my money on one approach, it’d be getting people to believe in themselves, with the support of those around them, and then channeling that positivity into action. Sounds vague—and as I think about Medivate I’m not sure how much of the current setup meets that test—but I think it’s worth putting out there for myself and anyone else who’s looking to build behavioral support systems.

To the event organizers, thanks so much! To anyone else looking to drive behavior change: good luck! As always, we’d love to hear thoughts, ideas, or anything else.

  • Mary Beth Schoening

    Excellent summary Fred. I was sorry to have missed the first session and was hoping someone would summarize. Thanks very much!

  • Karin

    Thanks, nice write up.