• Nadine Stunzi

Is an Educational Pamphlet Enough?

Behaviour; a simple term we are all familiar with that we understand as the ‘actions we take’. Often we act with thought and intention but not always, at other times some may say we act intuitively and others may even say impulsively. Economics for a long time was founded on the idea that humans are rational beings; making rational choices.

The well respected psychologist Daniel Kahneman started questioning this defacto concept of rationality about 50 years ago and interestingly discovered enough to win a Nobel prize. Many social programs and public policies are founded on this concept that if you just educate the public telling them what is needed, then the rational and correct behaviour will follow. If a doctor tells a patient to exercise they will hit up the gym, if the pamphlet says eat 5 fruits or vegetables/day people will consume such, or if budgeting will get you out of debt then surely you’ll watch your spending. If everyone could just muster up a bit more self-motivation society and the planet would be better off. But as Dr. Kahneman’s research has shown, behaviour is more complex than that. If behaviour was merely a rational response; we would see people eating better, exercising daily, spending within their means and conserving our natural environment. What is actually observed is that individuals repeatedly make decisions that undermine their long-term well-being (Duckworth and Milkman). In other words ,we often act in ways that don’t help us in the long term. To understand this trend and investigate how technology can help society make better decisions, a project called “Behaviour Change for Good” was initiated with some of the best researchers, thinkers and scientists around the world. They hope to determine the best behaviour-change practices in three realms: health, education and personal finance. The end game is to help people make better decisions, obtain short term satisfaction while bettering long term outcomes.

So what does this have to with physiotherapy? Well not a lot but it has a lot to do with health and if we know anything from the biopsychosocial model of pain, your general state of health is not separate from your current physical impairment. Health matters in the context of it all: back pain, knee pain, cancer treatment side effects, chronic fatigue etc. Furthermore, if behaviour change towards a healthier lifestyle was just a rational action, as stated above, then we’d all be there. But making better and healthier choices isn’t a simple behavioural change, it’s more complex than just listening to the advice from a clinician and getting it together. Maybe self-motivation alone just isn’t enough and strategy can be useful; strategy using some of the findings from the great thinkers mentioned above. Daniel Kahneman’s idea of behaviour is that it is an equilibrium, a balance between 2 forces: restraining and driving. A dance between influences that push for the behaviour and forces that limit. We have started to learn that incentives, threats, negative self-talk and in other words, ‘pushing the driving forces’ well isn’t actually that effective. Instead, focusing on the restraining forces and how they could be lessened has shown to be more impactful! Simple examples of valuable questions one could ask is in hopes to lessen the restraining forces are:

1) Why hasn’t the behaviour been adopted?

2) How can we change the environment to better support the change?

3) How can we make it easier to adopt this behaviour?

4) How can we add more context of how this change may better society at large?

So what might this look like in the context of health promotion and physiotherapy? Well instead of therapists just pointing fingers at patients who didn’t exercise or follow through with rehab maybe health professionals can create more space to ask the above questions. Perhaps instead of just handing out educational pamphlets or telling patients they need to exercise, clinicians can spend the time understanding the barriers that may be present in a patient’s life. In particular, put yourself in the shoes of a patient with cancer whose barriers to exercise are plentiful; would an exercise pamphlet be enough? Instead, what can we do as therapists to make it easier for our patients to engage in healthy behaviours? What kind of spaces can we create to start to talk about these barriers? These are the kind of questions I am asking myself daily, as I build a cancer rehab program; as its foundation lays on creating behaviour change for good. What can we offer in the environment to support healthier decision making? I like to believe that socialization, fun, positivity and accountability are all environmental supports that help make exercise easier. So much learning ahead, that's for sure! I hope that through my programs and the relationships that ensue, ‘restraining forces are lessened’ and just maybe cancer patients are able to make good choices with a little more ease.

Podcasts: Freakanomics Radio How to Launch a Behavior-Change Revolution (Ep.306)

Daniel Kahneman “Thinking Fast and Slow” (free to listen)