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Dr. Aw Wellness Update: Are you ready for a behaviour change?

These pandemic times have allowed us to reflect about what is important to us. One of my summer books that I read was “This Could Be Our Future – A Manifesto for a more Generous World.” written by the founder of Kickstarter, Yancey Strickler (1). It challenges us to be better versions of ourselves through a “Bentoism” philosophy (hara hachi bu) to ensure balance and harmony. It expands our view of self-interest (Now Me) to focus on our current behaviours and choices that will affect whether we live up to our personal ideals (Future Me) and how it will affect everybody else (Future Us). This read raised a good question. Is it possible that you and society will come out as better versions of ourselves after this pandemic?

One of the most challenging aspects in my medical practice is driving healthy behavioural change in patients. We all know that we should exercise, eat healthily, lose some excess weight, avoid smoking and don’t drink too much. Unhealthy behaviours can contribute to more than 40% of the incidence for non-communicable diseases like cancer (2). So why is it so difficult to change behaviour?

The COVID-19 pandemic has highlighted the challenges of behaviour change for the public. Compliance with masks, physical distancing, hygiene, etc. have played out differently around the world. Some countries have done better than others in containing the spread of the virus. Germany set up the COVID-19 Snapshot Monitoring (COSMO) initiative (3) which is a rapid evaluation tool based on weekly online surveys of 1,000 participants to capture what the public thinks and feels during the pandemic. Some of the findings in March 2020 was that knowledge of COVID risk was high – but protection behaviours were very low and risk perceptions were especially low in the elderly. COVID has hopefully taught us that our personal choices and behaviours (i.e. wearing a mask, distancing, acts of kindness, etc.) have a huge health impact on those around us (particularly the most vulnerable). The “Now Us” (pandemic) determines the “Future Us” (post pandemic).

The World Health Organization has now adapted the COSMO protocol (4). Behaviour change of the masses in a global health crisis is complicated. The infographic below illustrates the different aspects that influence our actions and belief systems (5).

https://www.nature.com/articles/s41562-020-0884-z

Infographic depicting a selection of topics from the social and behavioural sciences relevant during a pandemic. Topics covered here include threat perception, social context, science communication, individual and collective interests, leadership, and stress and coping.
So how should we approach behaviour change?

So how should we approach behaviour change? The Behaviour Change Wheel (6) is a nice academic model that incorporates 19 behaviour change frameworks. The hub of the wheel is made of three important concepts: capability, opportunity and motivation (COM-B system). Around the hub are nine interventions and surrounding this are seven categories of policy. As an example – increasing physical activity and healthy diet may include interventions like education, persuasion, incentivization, training and enablement. Capability means one’s psychological and physical capacity to engage in an activity as well as having the necessary knowledge and skills. Motivation incorporates goal setting, analytical decision making, habits, emotional response and the ability to energize and direct behaviour. Opportunity involves factors outside the individual that make the behaviour possible or prompt it.

By now – you are probably getting a sense that there are so many elements to changing behaviour!

Let’s drill this down into some clear actions and try to use some real life examples like losing excess weight and wearing a mask during a pandemic.

  1. Find your Motivation: An essay in the Lancet journal (7) by a Cambridge professor opined about applying economist Daniel Kahneman’s theories on Thinking Fast (unconscious mind – emotional, instinctual) and Slow (conscious mind – goal setting, analytical) to behaviour change. As an example – if you were trying to lose weight then slow thinking would be saying that you will lose a certain amount of weight by January 1, 2021 or train for a personal best time at an upcoming race. Examples of fast thinking to motivate weight loss would be trying to fit into a dress/suit for an upcoming wedding or avoiding the need for prescription medication for your cholesterol (emotional drivers). Motivation is also described as automatic (fast) and reflective (slow). Fast thinking to motivate one to wear a mask in public would be to comply with the public health rules (i.e. sense of belonging, avoiding scrutiny if you don’t wear a mask in public) and avoiding infecting others. Slow thinking might be to help your community decrease cases so that we can get our children back to school. The call to action is to determine both your fast and slow motivators. We need both for sustainable change!

  2. Create Daily Healthy Habits: Changing your environment can also be done through the creation of healthy cues and nudges. “Cueing” would be the creation of new habits such as having a glass of water every time you crave a snack. A cue for mask wearing is to just wear a mask when you leave your house. Create your own mask rules (i.e. Safe “no mask” zones = home, outdoors if physical distancing, safe social bubble) and Risk “mask” zones = indoors, close prolonged contact with strangers/outside social bubble, etc.). “Nudging” would be akin to only eating food on small dessert plates for all meals (i.e. portion control). A masking nudge would be to place cloth masks (buy several) in easily accessible areas when you leave the house (i.e. masks in the car, at the door, handbag, etc.). Make it easy to grab a mask and always have a good supply. Buy or make masks that you don’t mind wearing (i.e. comfortable, proper fitting, designs that fit your personality, etc.).

  3. Keep it simple and make change purposeful. If the behaviour change interventions are simple – then you will probably stick to them. Attach meaning and purpose to your actions.

  4. Manage your emotions. Emotions can drive perceptions and behaviour. Practice mindfulness based meditation and be in the moment. Stay positive! Celebrate your wins! Nurture your social support network. Learn from the setbacks. Keep the faith.

  5. Stay informed. Avoid fake news, fads and the conspiracy theories. Get the facts from the experts.

Are you ready for positive change? Will we come out of this pandemic a better version of ourselves?

You are the expert on you. Start where you are at.

Take a personal inventory of your wants and needs. Where do you want to improve? How would you like things to turn out?

What does a Future You and Future Us aspire to be? Think big.

How’s your Behaviour Change Wheel? Build a change plan and keep yourself accountable. Little changes can make a big difference.

Remember - our daily actions affect not just ourselves – but everyone around us in the now and the future. Personal improvement and acts of kindness should have a halo effect. It’s not just about you. It takes a village. We are in this together!

References
https://time.com/5717867/bento-box-change-world/
https://www.cancerresearchuk.org/about-cancer/causes-of-cancer
https://www.nature.com/articles/s41562-020-0866-14.
https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/technical-guidance/who-tool-for-behavioural-insights-on-covid-19
https://www.nature.com/articles/s41562-020-0884-z
https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42
https://www.phpc.cam.ac.uk/pcu/art-medicine-changing-minds-changing-behaviour/