October 24, 2019

Does Information Change Behaviour? By Alex Pearson

Jeff Stevens sat in his doctor’s office. It was quite impressive, a new build; lots of white gloss panelling and stainless steel. The nice receptionist had been efficient, the surgery wasn’t running too far behind, and now he was sitting in front of his doctor, uncomfortably aware of how loudly the wall clock was ticking while his doctor shuffled through some papers.

Well, Mr Stevens, as you can see here…

Jeff leant forward to peer at the sheet of paper under his nose, as the doctor indicated a row of numbers that Jeff wasn’t sure he understood.

Both your cholesterol and your blood pressure are high. This could lead to a heart attack or a stroke in the near future. Did you know that strokes are the fourth leading cause of disability in the United Kingdom?”

Oh, okay!” Jeff knew that definitely wasn’t a good thing, although the exact reasons why escaped him. He did, however, have a good idea of what was coming next.

Both of these could definitely be improved by becoming more active and losing some weight. As you can see here, your BMI is 29, which puts you just one point away from falling under the obese category. In conjunction with your cholesterol and blood pressure results, these are all considerably increasing your risk of having a heart attack or a stroke.

Jeff nodded, hoping his concerned expression conveyed how seriously he was taking this information.

Now, there’s plenty of literature on the subject of making healthy changes to your diet and simple ways to become more active. All good stuff in here, please take them away with you and have a good look through when you get the chance!” The well-meaning doctor thrust a bundle of trifold leaflets into Jeff’s hand, full of smiling ladies in activewear, pictures of apples with tape measures wrapped around them, and overweight people looking happy while jogging.

I would like to see you again in 12 weeks, and we will see if you have brought those levels down. If not, we may have to look at medication. Take care!

When Jeff got home he took his doctor’s advice to heart and spent some time sitting earnestly reading through his new leaflet collection.

Consume more fruit and vegetables!

Take more walks…try and increase your step count to 10,000 a day.”

Stroke is the fourth single leading cause of death in the UK! It is also a leading cause of disability in the UK – two-thirds of stroke survivors leave the hospital with a disability.

Jeff had heard a lot of this sort of thing before. He had a rough idea that the key was to reduce things in order to see improvements – reduce calorie consumption, reduce cholesterol, probably something about reducing fat because cholesterol is something to do with fat and that’s bad? Either way – time to give it a good go!

Does This Information Overload Change Jeff’s Behaviour?

Does Jeff succeed in losing weight? Changing his blood pressure? Reducing his cholesterol?

Does the information about the risks present in his current, or future, situation, change his behaviour? Does the information about diet and exercise help him change?

It is a very seductive idea: provide appropriate, well-meaning, accurate and helpful information, and people will act differently. All we need to do is tell people the right answers, in the right way, then they will change their behaviour! We need to explain to them all the risks associated with their current behaviour, and why they would be better off behaving in a different way. Then, people will be more rational and see that the benefits far outweigh the costs. All that potential struggle and misery avoided!

This is the exact trap that health policymakers have been falling into, time and time again, over the last 60 years, as we attempt to change the biggest threat to health in the modern western world: the big four noncommunicable diseases – cancer, CVD, type 2 diabetes and respiratory disease.

Acute conditions are primarily dealt with by doctors by making a diagnosis and then giving the patient appropriate treatment. Unfortunately, in the context of getting people to change their behaviour, this particular medical model does a very poor job.

There are four behaviours in particular that have an enormous impact on a person’s health, and I have no doubt they will be of little surprise to anybody reading this: tobacco use, excessive alcohol consumption, the consumption of highly-processed foods leading to excess calorie intake, and physical inactivity.

The long-standing idea that health professionals (of all types – doctors, nurses, personal trainers etc.)  are there to provide “evidence” and information has its roots in a theory called the “subjective expected utility model”. Put simply, the idea is that when this model is applied to health behaviour, you focus on the threats to the patient’s health, tell them the correct ways to negate these threats by changing their behaviour, and then the patient will change! Many specific behavioural theories branched out from this concept, including the Theory of Planned Behaviour, the Health Action Process Approach, and even the more commonly known Stages of Change.

However, human behaviour is a lot more complex than a simple decision calculus where we weigh up the costs and benefits of a given course of action, then act in accordance with the outcome. We actually shift between two categories of behaviour.

Two Categories of Behaviour

One is slow, cumbersome and reflective, requiring focused attention. We use it to direct ourselves towards goal-focused behaviour. It absorbs our attention and can be massively inefficient when it comes to our everyday situations. Why waste resources deliberating about the best way to get to work in the morning?

The other is fast, reactive and automatic. We respond to our environment and situation in any number of complex ways, while our conscious thoughts could be elsewhere. These automatic behaviours, therefore, can easily become disconnected from our conscious desires. This is where health behaviours often fall. We act automatically in ways that are completely at odds with our more conscious needs or wants. When engaging in the hundreds and hundreds of other things that need to take up our attention, we proceed to act on autopilot, guided by our environment, our situation, our experiences, and thousands more variables besides.

So, now consider, when we try to educate people by providing information about risks, or telling them how they should eat, or all the different ways they can exercise, which part of their behaviour are we attempting to appeal to? Yep – the slow, deliberate, “rational” part. But, as we have seen, that’s only half the picture, and we are left with the unfortunate truth. This is way many of us can perform behaviours that we know could be doing us harm, but still continue to do them!

The evidence on human behaviour overwhelmingly shows us that information alone does not change behaviour. Knowledge and rational assessment alone do not drive behaviour.

The way we eat, move, drink, the routines we create, are essential to who we see ourselves to be, both to ourselves and to others in the world around us. The idea that if we simply provide people with different information then they will change, not just their behaviour but their entire sense of self, is excessively superficial.

So try to catch yourself next time you try to create adherence in your clients by providing more and more information; whether that is information on risks, benefits or even “how tos”. Sometimes it can be misleading, as we have all seen appropriate education impact a client positively – after all, information and education are brilliant when someone is already undergoing the process of change or a lack of knowledge is the main barrier for an individual who is already eliciting examples of change.  However, those people are in a completely different place to someone who isn’t showing those signs.  To become more ready to embrace and then execute changes relies on a lot more than just information.

Interested in hearing more from Alex Pearson? Listen to his podcasts on obesity and motivational interviewing.

What About Jeff?

Let’s return to Jeff. After reading those leaflets, does Jeff change his behaviour? 

Well, as we have already seen, we are trying to change Jeff’s automatic behaviour through education; as a tactic this does not show a lot of promise. Jeff might also not be actually ready to change, which provides another stumbling block. But the risks are right there in black and white in front of him! Surely he can’t ignore them? Well unfortunately…yes he can.

There are at least four different theories as to how people can psychologically circumnavigate health education. I’m sure you will all recognise at least one of these.

  • Health belief model: An outcome of the Health belief model might be that someone believes the following… “I believe that being overweight is harmful, but I don’t feel particularly vulnerable to those risks, therefore it won’t happen to me!” This individual doesn’t feel susceptible to the risk associated with being overweight therefore the known risks don’t feel relevant to them.
  • Terror management theory: “We are all going to die at some point. So I may as well enjoy myself while I can!
  • Social learning theory: Everyone is overweight nowadays. My friends and my parents are overweight! My dad lived to 92! They are all doing fine!
  • Selective attention: “Smoking might not be great, but it has the advantage of helping me manage my weight!

Just like that, all the statistics and risk factors and potential disease disappear in a puff of smoke. All beautifully circumnavigated by the human brain in one fell swoop.

What About The Communication of Risk/Negative Outcomes, to Stimulate Motivation to Change?

Here we can look to self-determination theory (SDT) to understand what we may be doing to motivation. In SDT, we look at motivation in terms of “internalisation”, which means how valued or autonomous a new behaviour becomes over time. The least autonomous form of motivation is external regulation, which is where people are motivated to either gain rewards or avoid negative outcomes. Sound familiar?

The more information is given about avoiding the negative outcomes, the more someone’s external regulation is reinforced. Now, that’s not necessarily a bad thing; if that’s where someone is, we need to meet them there. But equally, we need to acknowledge that this type of motivation is related to less long-term adherence to behaviour change.

Ideally, we would want people to become more self-determined and less externally regulated. More information, particular about the risks, is unlikely to do produce this result.

What About Information or Education on How to Change?

There was a lot of information in those leaflets on how to make changes, and Jeff’s doctor definitely told him plenty. Surely that will help?

Well, apart from the issues we have already discussed, we now run into the problems with human memory.

A comprehensive body of literature suggests that, unfortunately, people simply do not remember what they are told well.  When told medical information, 40-80% is instantly forgotten. Of what is actually remembered, 50% is incorrect. That percentage increases the more information is told in a given sitting, and with increasing complexity of information.

So as we can see we have many different facets to the issue of information changing behaviour.

We have the fact that information does a poor job of changing automatic behavioural processes.

Let’s imagine a world where this is not the case, and we assume that information can change the automatic processes that people rely on to get through daily life; any education or information given would need to be A) accurately recalled, B) thoroughly understood, and C) be practically relevant and applicable. In other words, even if information were shown to have the effects that we want, which it doesn’t, there would already be so many other barriers in place that it would be extremely difficult to have any success with a client changing their behaviour.

Next, we need to have both the social and physical opportunity to behave differently. The social opportunity would include things such as our cultural norms, or our social cues. The physical opportunity might be dependent on location, time or resources.

Then finally, we need to have the motivation which encompasses both automatic processes (for example our desire, habits or environmentally triggered behaviours) and reflective processes, as we discussed above.

Once all this has been taken into consideration, we then need to get around the issue of just how good the human brain is at providing us with “workarounds” for what it has been told is the case, such as the potential outcomes of the Health Belief model or Social Management Theory. These so easily allow us to dismiss whether we think the risks presented actually apply to us and have any relevance to our lives.

And all this even before we take into account the possibility that our clients haven’t even remembered half of what they’ve been told in the first place!

Now, Think About Your Clients…

Do you have any clients with whom you are frustrated, or confused, by their lack of willingness to change? Despite how often you have explained things to them? Despite the fact that they are acutely aware of the negative consequences? Well, don’t worry – it’s not you. Information alone will not get them there, and I suggest that you save the undoubtedly wonderful information you have to share for later, when your client is ready to change. If you have already tried this route and it hasn’t worked, and you’re wondering if a second round might do the trick….it won’t.

Remember that it isn’t so simple as people not knowing why being overweight or smoking is bad, and it’s definitely not just so simple as people needing to understand how “easy” changes are to make, because change for most people actually isn’t easy to make, and we do millions of people a massive disservice by suggesting that it is.

Find Out More About LTB

If you would like to learn more about Alex Pearson’s work, you can watch his obesity course, childhood nutrition and hypermobility webinars by clicking on those hyperlinks. Not a member? Sign up to our two-week free trial!

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