In a recent poll, people indicated interest in maintaining brain health but expressed ignorance on how to do so. In a second poll, most men believed the herpes vaccine was only for young women, while in a third poll, only about 50 percent of women were aware of the importance of breast cancer screening. Other polls on health care information knowledge have shown similarly large awareness gaps. Given the substantial sums of money spent on health education campaigns, these findings question whether the return on investment (ROI) justifies their cost.
ROI for health education depends on the endpoint measured. If a campaign is to increase vaccination, this is relatively easy to assess. However, a result that may occur years in the future or that is complex is more difficult to determine. Assumptions must be made, and it is difficult to know whether they will be valid for years or decades. For example, if a campaign urges people to make lifestyle changes now to minimize diseases that may occur 40-50 years hence.
From the receiver’s perspective, two significant, compound, and intertwined factors determine a message’s effectiveness: relevance and reality, and broad-based health messages deal with them ineffectively. Frequently, relevance is emphasized through negative consequences: “If you do not do X, Y can result.” However, fear and avoidance of a negative outcome are miserable motivators. Behaviorism has clearly demonstrated this for decades, but health messages continue to use these approaches. Marketers have taken this lesson seriously, though, as commercials show positive outcomes. For example, people eating potato chips exhibit enjoyment, not an individual in a casket who presumably died from a coronary occlusion. Our brains do not make this connection, as the avoidance of a potential negative (e.g., heart disease) is not interpreted as a positive.
Then, too, relevance is time-sensitive, and time can be considered in more than one way. For example, a health message that is unimportant at a given time in a person’s lifecycle is wasted. Information on herpes vaccination is irrelevant to parents with children who are either too young or to parents whose children are adults.
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Another aspect of time is how long we are asking a person to sustain a change. Here too, the thought of doing something for decades when there is no guarantee that the avoided heart attack resulted from the modifications continued for 30-40 years or more presents little justification for these changes. The promise of possibly avoiding a heart attack or a stroke at an indeterminate future is too distant to be rewarding.
A short-term reward triggers the release of a brain chemical that makes us feel good. If it occurs close to an action, it reinforces the action and increases the likelihood it will be repeated. A delayed outcome does not have this effect and is more likely to extinguish than reinforce behavior. Providing a short-term, tangible something that generates repetition can be challenging in adults, as research has demonstrated. In certain populations, for example, a small-value gift card has worked. But not for everyone or all the time. Multiple alternatives with frequent variations have been necessary as each quickly loses value, and the rewards that work with adults are limited.
Another major hurdle with developing a desire for healthy behaviors is their tangibility. Yet, the benefits of healthy behaviors are usually not visible, making them weak motivators. Lowering blood pressure, for example, is invisible to the patient. Readings on a machine, either at home or in a clinician’s office, are ephemeral and intangible, and aside from a brief comment by the clinician, too little praise and encouragement are provided to patients. Though intangible, they are nonetheless powerful reinforcers. Ringing a bell accompanied by applause and congratulations, as is done with cancer patients, can also provide strong reinforcement. This positivity is further tempered by our knowledge of others who did everything right yet died young of a stroke, and/or an obese person who lived into their eighties without negative consequences. These anecdotes, while unscientific, are concrete and more salient in decision-making than future abstractions.
Both tangibility and near-term results are essential and need to be created. For example, when I worked with obese people with poor health, I had them ignore whatever goal their clinician recommended, and had them target a five-pound loss; a goal that can be achieved quickly and visibly. After this was achieved, I gave them another five-pound challenge. This, with positive feedback from me and significant others, a valued reward, was effective in achieving weight loss and reducing health risk. The total is important, but as with New Year’s resolutions, it comes across as overwhelming and impossible to accomplish, and effort is quickly extinguished. Praise and encouragement must be genuine, not fatuous, and must come from those they value: partners, clinicians, etc. I often had to train them to do this, as it does not come as naturally as criticism.
In other words, while the advice in health care campaigns makes logical sense, our brains are not built to work with it, and we must devise alternative ways of presentation that make them more effective on a short-term basis. A major problem with the glucagon-like peptide-1 (GLP-1) drugs is that too many fail to make the necessary lifestyle changes with them but depend on the drug only. As a result, many regain significant weight when they stop the drug, and nothing is done to decrease their risk of high blood pressure, clogged cardiac arteries, and possibly Alzheimer’s dementia.
M. Bennet Broner is a medical ethicist.
