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Giving a nudge

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It is the time for New Year resolutions, and in surgery that is likely to include conversations around activity levels, smoking, healthy eating, alcohol consumption etc.

I’ve been spending time thinking about health promotion and behaviour change, their differences and what I can be doing with my patients.  I’ve been reading about what makes effective health promotion campaigns, be this in the subjects outlined above, and also in areas we now take for granted such as wearing seatbelts when driving. 

I’m struck how behavioural science shows that population and individual change are interconnected.

Health promotion campaigns are about population level change, whereas in our face to face contacts in surgery we’re dealing with individual behaviour change.  We are aware how we can use techniques such as motivational interviewing to aid this, or resources such as exercise on prescription to help people around the cycle of change.

However change in the macro environment also influences individual change.  We’re all used to suggesting that everyone in a smoking household quits together as this is more likely to be successful for each individual.  Scale this up to a population level and we’re more likely to cycle to work if there is a route that we perceive as pleasant and safe rather than contending with a busy, polluted main road. 

Ie for an individual to change their behaviour, a supportive wider population level environment is helpful. 

But there is something even more subtle about the environment that can be used at both population and individual level change.  In their book ‘Nudge’ (Economist book of the year in 2008) Thaler and Sunstein propose that human beings can be encouraged to make life-improving choices through incentives and social cues rather than through regulation and government legislation. 

Number 10 has latched onto this and has created a behavioural insight team who describe their work as ‘finding intelligent ways to encourage people to make better choices for themselves’.  For example, behavioural science shows how social norms ‘nudge’ people to change their behaviour.  This is because at some level we operate on a herd mentality.  Brand marketing and social media are testimony to this.  Therefore on a macro-level we can be encouraged to conform to, for example, paying our tax bill by being told 90% of people on our street already have.   Similarly there is no reason why we can’t use similar psychology artfully in our individual consultations.  For example, suggesting more people are walking into town rather than cycling, or that lots of people are using the Mediterranean diet and finding it helpful.

There has been an ethical debate around whether politicians and legislation should be engineering how society lives.  And there is obviously that debate within medicine.  I’m not asking you to lie, but in reality we’re always influencing people’s choices and this may be another part of our armoury in behaviour change.

The beauty of this is that if people really do start to make some of these basic changes, the population as a whole will be nudging in the right direction and primary care won’t have to carry so much of the can for fixing societal health.

Alex Thomson-Moore, an ST2 in the Severn Deanery.

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