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These two psychologists from Cardiff and Worcester in the United Kingdom, respectively, have continued on a path now becoming increasingly popular, or at least increasingly populated. Internationally, increasing awareness of the cost of treating illness has led administrations to ponder the sustainability of both private and nationalized health systems. The USA in particular, with people going into bankruptcy paying medical bills, and with blow outs in costs threatening to overwhelm the GDP, spends four times as much as any country that has universal health care, without managing this itself. Canada, France, Australia, the UK, and other countries all manage on about $2000 a year per citizen. However, they are not immune to concerns, and sustainability, with a rising aging population and a shrinking taxation base, looms large in the government ministers' minds. It's not just an aged care problem: Americans, I learned at a recent DMEC convention in Portland, aged in their 30's and 40's, now consume more disability money than their ageing peers nearing retirement. Billions of dollars going into these youngsters, while their aged peers, 401K's lost to Madoff and meltdown, are much healthier, and staying at work.
Most companies, driven by behemoths like United Health Group, Mayo Clinic, Kaiser Permanente, Sutter, Aetna and so on, have wellbeing products, or some HRA and advanced outreach, but simply put, engagement and retention in any health scheme is lousy. 15% is good, even if incentivized by Amex gift cards and discounts at stores, to the tune of a few hundred dollars. This not only applies to body health, but brain health as well: A recent initiative advertized by a major insurer in the USA with 35 000 members to train the brains of its staff using an online tool, drew engagement with only a few hundred members, despite being heavily incentivized. Face to face is too expensive, and online solutions appear to be poorly structured to engage and retain people as successfully as Facebook and other addictive entities do. Another issue may be the stigmatism of ill mental and physical health: a recent offering by a peak performance athlete's health group to a huge computer company yielded 80 000 staff signing up for a web-enabled solution, a more positive message perhaps contrasted with a fear and avoidance based approach. When the Alliance for Ageing Research offered free online brain testing for its huge population of 50+ year olds, only hundreds, not millions or even thousands, took the test toolkit over the next years, Illustrating the fear drive model is not exact in its predictions of behavior.
This lack of self determinism is well known: diabetics are lax in motivating health habits in themselves, dieters are serial yoyos, 70% of antidepressant scripts are filled only once, and for every person at a health club, there are three who stopped going soon after joining up. Negative messages such as the avoidance of dementia or diabetes or depression contrast with what people actually do in engaging with health primary prevention, such as wearing seatbelts or driving only while sober. While diets for instance, all by and large reduce weight, they cannot be sustained as part of a reasonable lifestyle, and some may even kill, or produce very real health risks along the way.
The psychology of how people engage with healthy habits, and maintain their engagement in healthy lifestyles is thus a vital facet of any attempt by countries and corporates to change the awful effects of modern western existence on body and brain health. Speaking of which, integrated body-brain products and approaches are hard to find anywhere. With large scale ignorance of the brain's functions dominating the 19th and even well into the 20th century, focus was on the body, hence separating brain and body artificially, and creating a philosophical divide. Despite the focus on the body, most effort in science, as in psychiatry and psychology, was on pathology and the medicalization of treatment and putative curative medicines.
What has become increasingly true is that the vast weight of money and effort put into curative approaches neglects the simple truth: the enormous majority of the money spent in medical systems is wasted on diseases, illnesses and conditions that are lifestyle based, and thus preventable. The lifestyle our bodies thrived in across the millennia of evolution, is not the lifestyle of today, and mal-adaptation now results in diabetes, cancer, arthritis, dementia, depression and so on. An increasingly sedentary lifestyle means that we are moving far less than our parents and grandparents, estimated now at about a marathon a week by some experts.
The authors begin by evaluating the available theories on motivation and engagement with health risk and health changing behaviors, and the flaws and values of each. Risk Perception, Fear Drive Model, Health Belief Model, Protection Motivation Theory, Theory of Planned Behavior, Social Cognition Theory, and Stage Theories of Behavioral Change. Given that theoretically based interventions have had greater success than opinion-based interventions, the merits and pitfalls of each are worthy of investigation, and each is weighed in the balance. There are ample historical studies and failures to draw on, and they refer at times to such data.
The authors then set out to apply each in turn to various arenas of health change. Eating is the obvious starting point, with the authors identifying healthy diets, describing the extent of the obesity problem (in the UK, but not different to any other developed country), determining the socio-demographic factors associate with poor nutrition habits, and most importantly again, they look at the models of eating behavior and how successful applying these models are in prescribing interventions.
Physical activity is also a no-brainer, and the next chapter critically evaluates the connection between health and physical activity, as well as the 'obesogenic' environment, and the interventions that address this. Most important here are the reasons why some people engage in regular healthy movement, and some do not. Although most would recognize the need for at least 30mins of rigorous exercise a day, this probably only addresses the 8 hours we spend at a desk each day, and probably confers no health benefit apart from just keeping up with the effects of being sedentary, without building resilience and longevity. About a third or less of adults keep up to government guidelines on movement and exercise, which kind of says enough in and of itself. As with eating behaviors, movement and exercise confer benefits across a wider health spectrum than appears to be reasonable on the face of it. For instance, there is evidence that connects consumption of fish per capita with the depression rates per capita of countries, similarly with the murder rate. However, despite the government guidelines hardly being onerous, complex explanations are required to begin to address the underlying factors that feed into obesity and failure to exercise. Socioeconomic factors, and psychological factors play a part, including, as noted in the discussion of the models of change before, past experience of failure. Perceived behavioral control over potential barriers to exercise however explain more of the variance than other issues such as perception of threat. It's not a simple issue. As with many other issues, the most interesting aspect across the literature here and elsewhere is the concept of self efficacy. More than the external sense of perceived behavioral control, the idea of self efficacy, namely an internal sense that what I do makes a difference, and predicts success, has a greater weight.
Intrinsic versus extrinsic motivating factors also play a role, given the research that demonstrates that extrinsic rewards certainly motivate better outcomes when the task is mechanic: however, when a cognitive appraisal is vital in initiating emotions that drive volition, intrinsic motivators which include a sense of mastery and purpose, relatedness and autonomy both, the outcome is more likely to be engagement and success, as discussed in the beginning of the book.
Alcohol is ubiquitous in our societies, but seldom regarded as a source of ill health, until you realize that the proportion of men who exceed government guidelines on consumption during at least one day a week is around 60%. If these are the same 60% who don't exercise in keeping with government guidelines, and they most often are, and if they eat badly, as they do, the combinations build up with poorer outcomes as each layer of neglect is added. As noted above, just being ill with a disease where alcohol is a huge no-no, does not stop people consuming alcohol against doctor's guidelines, pointing out clearly the failure of interventions that rely on scaring folk out of unhealthy behaviors by pointing out risk of morbidity or mortality. Given that socially isolated people drink more, and that countries like the UK and Australia have long cultural traditions of drinking way past the limit of what would be desirable or even sensible, and given the role of alcohol in socializing, and the morbidity in those that don't successfully socialize, the pattern of causality in unhealthy drinking is complex and self-reflexive, and unlikely to change. Few models fully predict successful interventions entirely, but again, self-efficacy seems to be a key component of behavioral change, and especially important since the worst offenders are the youngest: challenging social norms here is thus another good intervention.
Smoking is of course a perennial health risk, with the highest load of morbidity and mortality across the spectrum of medical and behavioral conditions. The number of young people who take it up, remains the same, which says something about this group. The decrease in numbers who smoke worldwide is thus an outcome of established smokers who give up. Optimism about smoking outcomes is pervasive and resists the evidence that the outcomes are bad, and a cause of more avoidable illness and death than any other health behavior. Clearly cut here, more than other conditions, is the role of Motivational Interviewing and the transtheoretical model of change, allowing for recidivism and harm minimization.
Interesting, sexual behavior is another area for concern, given the rise of STD's and of course the presence of AIDS, especially in Africa and underdeveloped economies and nations. Again, self efficacy, understandably, is an important target for intervention. Illicit drug use is much the same, and 185 million users (2007 WHO figures) worldwide defy laws and sense in consuming substances that are never benign. 10% of adults in the UK have used an illicit drug in the preceding year, with a third admitting to some use in their lifetimes. The cost to the UK is more than $30billion each year. Many therapies based on a social cognition model, as well as other interventions, have shown reasonable outcomes.
And so to the meat of the book: the how-to manual. Here, it becomes clear that health promotion activities work, and that most people in developed countries such as the UK, understand what a healthy lifestyle means, even if they don't engage exactly with this understanding. My own experience is that people do not, avoiding foods essential to life, such as plant fats and carbohydrates, in favor of processed foods and medication, using principles of body building in the gym, rather than movement, mobilization, recovery, and functional outcomes. Further education, says the book, and campaigns to point out risk, are unlikely to evoke behavior change advancements in the broad population. Self efficacy and perceived behavioral control are, on the other hand, likely elements to successful interventions. Motivational Interviewing has been successful in this way, and any similar or other interventions that promote habitual adherence to elements of a healthy lifestyle, are worthy of attention. Goal setting and self regulation tools are thus essential, and empower behavioral change. Enjoying the habits, namely, they become addictive, is a powerful and essential feature of changed behaviors longevity in anyone's armory. More traditional information based campaigns in public health may be more effective than cognitive based persuasions.
Finally, objective reality is mediated by perceptions, and social, cultural and physical environments have their impact militated against by these perceptions.
The final chapter points out putative ways forward in the 21st century, which include good measurement tools, good tools for measuring and enhancing a sense of self efficacy, the need for healthy behaviors to become habitual, the role of social and family settings, and so on.
There are few books out there this comprehensive in terms of a strict adherence to using available models and to the recommendations that flow from these theories. There is very little direct research into what exercise works best, what pitfalls emerge from sugar and salt etc, but that is not the focus or rationale of this book, and is easily gleaned elsewhere, e.g. Cozolino on socializing, Ratey on exercise, and so on. What these authors set out to do is in the highest goal of the scientist practitioner, and is to be warmly received and carefully read.
© 2010 Roy Sugarman
Roy Sugarman, PhD, Human Performance Institute, Sydney, Australia