Changing behavior is difficult. It is also an increasing priority for health care. We have entered a period of history when lifestyle choices have a dominant impact on health and longevity. People are no longer dying young of incurable infectious diseases in significant numbers. Rather they are surviving long enough to die from their bad habits.
Further, health behaviors are having a huge impact on the overall cost of health care. So the motivation is greater than ever to impact public health by influencing behavior. Yet, we are not very good at doing this.
It’s not that we’re not trying – it’s simply that having a large influence on people’s day-to-day behavior is remarkably difficult. There is ongoing research looking at how to effectively change behavior at the individual and public level, but it is complex, often conflicting, and new techniques at best yield only marginal gains.
The default method for changing behavior has been education – explain to people what the risks are of certain behaviors and the benefits of changing. I tell patients every day, for example, the risks of smoking and why they should quit. Of course, they all already mostly know everything I tell them. I try to use the latest techniques, like motivational interviewing and social norming. I ask them what their health goals are, and explain that quitting smoking will help them achieve their goals, and I have many other patients who can do it.
But – the effectiveness of individual counseling is extremely low. A recent review concludes:
Physician brief counseling and trained health professionals’ intensive counseling (individual, group, proactive telephone) are effective with abstinence rates between 2.1% and 17.4%. Only practical counseling and motivational interview were found effective intensive interventions. The clinical effect of smoking cessation counseling is low and long term cessation rates uncertain.
Obviously individual counseling alone is not going to be enough, even with intense innovative techniques. Public health interventions are also needed. There are two general types of public health interventions, mass public education (such as public service announcements, PSAs), and regulation that is designed to make it more difficult to engage in unhealthy behavior.
The latter does seem to have an effect. Taxes on cigarettes, for example, are effective (although tobacco companies try to offset taxes with lower prices). Banning smoking in certain public locations is also effective. Attention is now turning to similar regulations to reduce obesity, such as the infamous proposed ban on large drinks in New York City. There are regulations on tobacco advertising, and on packaging.
The overall goal of such regulation is to minimize enticements for unhealthy behavior, and to make the behavior as inconvenient as possible.
What about PSAs? How effective is it to have commercials of the famous “this is your brain on drugs” type? Recent research has been looking at how to fashion PSAs for maximal impact. One recent study looked at 71 subjects exposed to ads with either strong content or weak content, flashy editing or plain editing.
Encouragingly, they found that having a strong message was the more important variable. If the PSA had a weak message then it did not matter if the editing was boring or flashy. If the PSA had a strong argument then it was effective even with plain editing, but more so with flashy editing. The study used fMRI to image subjects watching the PSA and found that strong messages engaged the decision-making part of the frontal lobes. They also monitored subjects a month later for urine nicotine metabolites and found the strong messages were associated with a decrease.
What this seems to indicate is that you have to grab people’s attention and deliver a persuasive message. What is still lacking from this research, however, is long term follow up.
Other research also indicates that the “scared straight” approach has limited long term utility. The strong message may benefit from the incremental gains offered by techniques such as motivational interviewing (engaging the viewer’s goals) and social norming (essentially peer pressure).
It seems that it would be highly cost effective to invest research dollars into improving the technology of altering public health behavior. There is no simple answer to this complex problem. No matter how you look at it, it’s very difficult to have a significant impact on such behaviors.
Likely any successful campaign will involve multiple components, individual counseling, PSAs, and regulations, each with an incremental effect but with an overall significant effect.
So far the most effective methods seems to be those that make it easier to engage in healthful behaviors and difficult to engage in risky behaviors. People still have choice, but the easy default choice is the healthy one.