The Department for Health and Social Care (DHSC)’s new 'health incentives' pilot
Like many others, Holly Health welcomes the Department for Health and Social Care (DHSC)’s focus on encouraging people to improve their diets and increase their physical activity. The pilot focuses on rewarding people for increasing their steps and vegetable consumption, via a points based app. It is widely known that a healthy diet and doing exercise can improve a person’s overall health and so this is a step in the right direction. Evidence suggests that a rewards system can work in the short-term: encouraging behaviour change by ‘chasing the carrot’, knowing that a reward will be earned for making each healthy choice.
But, there are two significant challenges with the way this new service has been designed:
- Oversimplification of health behaviour change…“take more steps, eat more veg”
- Lack of focus on intrinsic motivations for behaviour change.
Oversimplification of health behaviours
As is often the case with government health initiatives, this programme does not go far enough to recognise the core issues at play, which often lie deep within an individual. Focusing simply on steps and vegetable intake, and ignoring the more deep-seated reasons for behaviours, is a missed opportunity to support people psychologically, and in a personalised way. While some people will see benefit from this approach, it does not pave the way for long-term behaviour change, which is the ultimate goal for improving health at individual and population level.
There are often psychological complexities surrounding a health issue, such as obesity or eating disorders. For example, eating out of stress or as a coping mechanism when life is hard, or over-restricting food in order to gain some perceived control. Rewarding someone for eating broccoli won’t necessarily stop them from stress eating or drinking later. In looking at a food-related health condition, we need to assess what’s causing this behaviour by understanding where, when, what, how and why someone eats: the psychological, convenience, lifestyle and financial factors affecting meal-times and eating patterns. Every individual has their own unique challenges and blockers, so ideally interventions need to be personalised to their unique needs.
Rewards systems have been embraced by health insurance providers (e.g. Vitality Health), with great uptake, and clearly customers are taking a step towards improving their health by taking out health insurance. However, we need to look at incentives in other settings to predict how the public will respond to rewards, taking in local and cultural factors too.
For instance, a major challenge in lower middle income countries is getting people who have tested for the HIV virus to pick up their results. This is largely due to fear of receiving a positive result and therefore facing the reality of having and living with HIV. In Malawi, a programme that offered payment in return for individuals collecting their HIV test results showed to only incentivise 50% of those tested, leaving 50% non-fussed about the financial reward and it not changing their fixed mindset.
Intrinsic motivations for behaviour change
For long-term change, we need to build in individuals’ intrinsic motivations so the desire comes from within and not just from external factors. We need to ask, if the rewards were to stop, would the incentivised activities also cease? If people feel personally motivated to pick up a new activity that is well suited to them – for example, practising mindfulness each day to reduce stress – science shows that over time, this stops becoming a goal to reach, and instead moves on to being a natural instinct.
Points systems can be useful for attracting people to a service initially and the educational outcomes are certainly valuable and something we endorse. Such systems are a great opportunity to help make individuals aware of a specific type of exercise, or provide nutritional facts or recipes. However, with long term behaviour change as the goal, education and surface level information is just not enough. We need to rethink these traditional approaches to health promotion and prevention, to help people identify the best coping mechanisms for themselves when things get tough, and to identify and address their unique individual challenges – whether it be sleep, relationship with food, or finding the exercise habits which work best for them. It is the long-term purpose and impact of this health incentives system that we would encourage the government to rethink.
It is great to see the DHSC turning to digital technology to improve physical health and prevent health conditions – especially as individuals become more comfortable tracking their own health data – and we do, overall, welcome this move as a step forward. However, for this programme to really succeed, it will require smart, longer term thinking and utilisation of the best elements of modern technology, alongside innovations in psychological and social science.
Embracing digital solutions to help assess and manage health in a personalised and psychologically supportive way is where real, impactful change can happen.
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