Why is Changing Health-Related Behaviour So Difficult?

As a physiotherapist, I've spent my entire career trying to persuade patients to change their behaviour in one way or another. Whether it be following a specific program for their rehab, stopping smoking for their health or exercising more for their general fitness, Behaviour Change is at the core of all health and wellness professions. Yet we get little in the way of education or training in how to do this effectively and changing these health-related behaviours can feel like a lost cause at times.

A few years ago I was lucky enough to attend a lecture by Professor Michael Kelly of Cambridge University and was introduced to some of his work, including his paper: 'Why is changing health-related behaviour so difficult?' https://doi.org/10.1016/j.puhe.2016.03.030. 

In it, Professor Kelly reminds us that social context plays a role in individual behaviour and suggests that policy makers (and I would argue health care professionals) make six common errors when it comes to Behaviour Change. So what can we learn from this paper and what impact might this have on our ability to change people's behaviours?

Error #1: ''It is just common sense''

This is not only an error in itself, but also arguably leads to the other five errors. As such this is possibly the most significant mistake we make about Behaviour Change. We assume that ''understanding human behaviour is so obvious that it needs little or no serious thought''. But if changing behaviour is a simple matter of making simple changes and good choices, why is it so difficult? Evidence tells us that human behaviour results from a complex interaction of habit, automatic responses to the physical and social environment and conscious choice (Michie et al., 2014). The common sense approach results in costly, ineffective interventions like the Fruit for Schools Scheme http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Healthimprovement/FiveADay/FiveADaygeneralinformation/DH_4002149 .

Error #2: ''It is about getting the message across''

Based loosely on learning theory, this is, on the surface, an appealing approach. It predicts a ''simple response to a simple message''. Yet these models explain only a small part of human behaviour. Taking the lead from commercial advertising, campaigns such as Change4Life (which aims to increase physical activity and healthy eating amongst children) attempt to change what we know to be complex behaviours just by raising awareness. Rising obesity levels underline the programme's limited impact.

Error #3: ''Knowledge and information drive behaviour''

The traditional healthcare professional-patient relationship assumes an information deficit on the patient's part. And so we assume that if we tell people the negative impact of being overweight, for example, that they'll eat less. But we all know this rarely happens. This is because people rarely behave the way they do because they don't know about the negative consequences. Rather, there are other factors in their life that get in the way of them changing their behaviour. This brings to mind a tweet I once saw in response to the Chief Medical Officer's New Year tips for better health. The comparisons made with his tips underline how complex changing these behaviours really is:

Error #4: ''People act rationally''

Several psychological theories including utility theory, theory of planned behaviour and the stages of change model suggest that when faced with a choice, people seek to maximise their gains and minimise their losses. Yet interventions based on these theories have had limited success in changing behaviour (Marteau, Hollands, & Kelly, 2015). And this is because humans are not completely rational. We behave as we do not just based on logic, but also on other factors including our environment, identity and automatic processes such as habits and biases.

Error #5: ''People act irrationally''

But that is not to say people are completely irrational. It has always been a particular bugbear of mine to hear professionals arrogantly refer to people as foolish (or similar) if they behave against their advice. There is always an explanation for why people behave the way they do and persistent behaviours continue because they serve a function. If we fail to understand someone's behaviour, are we not the ones who are irrational? Taking time to ask about the meaning of a behaviour can reveal so much about why it continues.

Error #6: ''It is possible to predict accurately''

With so many factors influencing behaviour, it is impossible to accurately predict how an individual will behave in a given situation. Whilst ''prediction is simple; it is far less effective and accurate than unravelling the cause''. And so we are encouraged to ask not ''could I change this person's behaviour by applying 'X' theory or 'Y' intervention?''  but instead to consider: ''why does this person behave the way they do?''. By understanding why people do the things they do from their perspective, we might be able to work with them to change behaviour.

So what does this mean for our day to day practice?

Common sense tells us that if we get the message across that certain behaviours are bad for them, people will make the rational choice to change in predictable ways. This paper shows us that this is not the case. ''Behaviour change is neither obvious nor common sense''. ''Behaviour exists above and beyond the individuals who do it'', and can only change when we understand the person's perspective of what drives it so as to empower them to generate their own solutions.

References

Kelly, M. P., & Barker, M. (2016). Why is changing health-related behaviour so difficult? Public Health, 136, 109-116. doi.org/10.1016/j.puhe.2016.03.030

Marteau, T. M., Hollands, G. J., & Kelly, M. P. (2015). Changing population behavior and reducing health disparities: Exploring the potential of “choice architecture” interventions. Emerging behavioral and social science perspectives on population health. Bethesda, MD: National Institutes of Health/Agency For Healthcare Research and Quality, 2015, 105-126.

Michie, S., West, R., Campbell, R., Brown, J., & Gainforth, H. (2014). ABC of behaviour change theories. London: Silverback Publishing.