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By Bradley Stulberg
Health behavior change is hard; if it were easy, everyone would be doing it. But running a marathon is also hard, and lately it seems that just about everyone is doing it. The health care industry could learn a lot from the increasing popularity of the marathon about how to design programs that help people make positive health behavior changes.
At its core, running 26.2 miles has much in common with the process of health behavior change. Both are physically and psychologically challenging, require a lot of will and at least a basic level of skill, and can be quite uncomfortable. But the two diverge when it comes to the experience of running a marathon, which is filled with allure. Ask yourself: Would so many people be eagerly volunteering (and paying!) to run marathons if the vast majority of preparation was completed in isolation and if the race occurred on a self-measured back road with at most a few family members watching? Highly doubtful. Yet this is often what people are asked to do when making health behavior changes, and then we wonder why so few succeed.
The good news is that by evaluating the total marathon experience, we can identify key components that make running an entirely unnatural distance so appealing, and consider how we might apply them to health behavior change. Remember, very few people are drawn to running 26.2 miles, but hundreds of thousands become absorbed with and triumph in the experience of a marathon. Perhaps it is time to start designing health behavior change solutions in the same vein.
So here are five things health care can learn from the marathon experience to promote behavior change:
Nearly all successful marathoners follow detailed training plans that are rooted in evidence. Since it is not pragmatic for most athletes to pursue in-person coaching, many (including professional runners) use programs founded on Web-based communication with varying degrees of telephonic interaction. This technology enables consistent contact in a highly accessible manner, allowing the athlete to easily incorporate being coached into the rest of her day, and the coach to have a broader, more scalable reach of his services. Digital coaching platforms are highly evolved; nearly all are user-friendly, facilitate data sharing, storage, and tracking, and are often available on demand via computer and smartphone.
There is no reason that care management or health coaching cannot be delivered similarly. We need to transition from a world where health care is provided in person from 9-5 to one where it is accessible to meet individualized needs and is more seamlessly interwoven into a patient's day. This is especially true for issues rooted in health behavior change, where the gains of technologically-driven remote access are likely to outweigh what little may be lost by not having all visits face to face.
Training groups are an integral part of the marathon experience. They provide will and skill support, foster accountability, and make it hard to quit (i.e., leave the group). Thanks to technology, nearly all training communities have an online element, and many are based solely in cyberspace. We can (and have, see Weight Watchers) do the same with health behavior change. An explicit role for community should be designed into nearly all health behavior change programs, and given the proliferation of online social networks, it is easier than ever to do so.
Some of the earliest advice I got upon signing up for my first marathon was to get new shoes, a fancy GPS watch, and nice Dri-Tech clothes. Not only did these things make running more comfortable (shoes and shirt) and meaningful (data from the watch), but they also turned me into a "runner." Besides feeling obligated to use all this cool gear, simply having it around my apartment served as a constant reminder of the journey I was on and the runner I wanted to become (for more, see research on the power of "artifacts" to influence culture and behavior). Why not go for the same effect by providing patients with gear that is appropriate for their desired health behavior change (e.g., sleek wireless scales, modern kitchenware, wearable biofeedback devices, user-friendly smartphone apps, etc.)?
Nearly all evidence-based marathon training programs are progressions that include races of shorter distances. These events serve as checkpoints to celebrate incremental success, or in some cases, to reevaluate and refine. Either way, if the coach is knowledgeable (see #1 above), if the checkpoint races are shared with the community (see #2 above), and if the athlete is using cool gear (see #3 above), these milestones are almost always positive emotional experiences that promote energy toward the long term goal. Research has demonstrated a similar effect of feel-good checkpoints when it comes to health behavior change. The "Upward Spiral of Positive Emotions and Health" says that positive emotions lead to improved physical health, which leads to more positive emotions, which leads to even greater physical health, creating an "upward spiral." Including milestones and designing them so they are likely to be received in a positive light ought to be a regular part of health behavior change programs.
Marathoners love wearing their accomplishments on their sleeves (or sticking them on their bumpers). While it is questionable if broader society holds the marathon in such high esteem, everyone in the running community most certainly does. Groups of individuals set out to change common health behaviors should be encouraged to view their shared goals with great pride, too. Imagine how powerful it could be if instead of being made to feel negative about their current health problem, patients engaged in [weight loss, tobacco cessation, sleep, etc.] programs were encouraged to take pride in their honorable quest for health improvement. A simple change in framing combined with a community of like-minded individuals can go a long way to shape attitude, identity, and subsequent stickiness to a plan.
The key components necessary for successful health behavior change are not much different than those necessary for completing a marathon. Perhaps the most encouraging part of this parallel is that once the desired behavior is practiced for long enough, many of the experiential bells and whistles may no longer be required to sustain it. Most accomplished marathoners can't live without running; it becomes a part of who they are and a way of life. Why shouldn't the same be true for healthy behaviors?
Rather than thinking of health behavior issues as problems that must be fixed, we should think about designing captivating health-promoting experiences. There is no better time to jump-start this sort of transformation in our approach to health behavior change than now. Bolstered by the talents of an increasing number of innovative designers, programmers and engineers who bring fresh perspective to the industry, health care providers should invest in modern tools and platforms to develop appealing approaches to help people promote and sustain healthful behaviors.
Readers? Thoughts? Reactions?
This piece also appeared on the Huffington Post. Brad Stulberg (@bstulberg) works in population health for a large integrated system in Northern California. He moonlights as an endurance athlete, where he does his best thinking on the trail.
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