Change health behavior with a gentle nudge

Gentle nudges is a concept termed recently to describe a micro-choice movement that is beginning to carve out a sizable niche in the healthcare start-up space, and is gaining a lot of well deserved national attention.  The secret ingredient relates to the power of a gentle nudge; verbal, text or otherwise to accomplish a change in the behavior of the person who receives the nudge.  We are just starting to scratch the surface on this remarkably powerful concept. Even the elite scientific community has verified the power of a gentle nudge from a person’s dense social network.

The folks at MIT have recently proven that people with dense social networks are more likely to acquire healthy new behavioral patterns.

Thanks to the early efforts of Contagion,  Goinfeld and PremierLogic (@Jensmccabe, @textandshout and @chadosgood respectively),  I believe this previously under-ventured space is getting ready to ignite. In addition, the entrepreneurs in this space (me included) may be able to accomplish  in short order, what medicine has not been able to accomplish for at least 100+ years. Motivate sustainable, incremental healthy behavioral changes amongst our patients with the use of gentle nudge technologies.

Why the excitement?

  • Traditional interactions with your physicians have a very small chance of leading to a meaningful, healthy change in your behavior.
  • Most physicians do not have the time, desire, nor monetary incentive to follow through with you after you have left their office.
  • It is fairly well proven that the advice you receive from your physician rarely results in meaningful or sustained positive behavioral changes.
  • The 30 day re-admission rate to institutions is unacceptably high.
  • There are many patients with hypertension who stop taking their medications because “they feel fine.”
  • A very large number of patients do not refill chronic medications.
  • And, from my own personal experience, many post-surgical patients do not follow well described, well articulated, printed,  post operative protocols.

More than a few articles on the subject coldly referred to this as self management.  Not only is the term cold, it is simply wrong.  If people were capable of modifying their behavior on their own there would be no need to write this post and our obesity rate would be 4-5%.

A few months ago the Wall Street Journal wrote about the positive behavioral changes brought about by a simple telephone call or voice message.  Great concept, but telephones are so passe.  Do you answer all your phone calls now?

What is the appropriate medium from which to nudge someone?   This is clearly a case where you need to be sure of your message, and the intended audience whose behavior you wish to modify.

How do gentle nudges pair up with mobile technology? Well, mobile phones have the great benefit of being in the pocket of more than 90% of all Americans.  Text messaging, the unsexiest part of mobile, is used by most Americans, with the average person under 55 years of age texting more than calling.  Lastly, in many minority communities, the mobile phone has replaced at home Internet access, bridging the digital divide in many urban and rural areas.

That said, how do we use mobile phones to affect healthy behavior change?  The simple answer is to do whatever is being proposed for Twitter, Facebook or iPhone and make sure it runs on SMS.  Want to know when your friend stepped on a scale and lost 2 pounds?  Text it.  Or where the nearest farmers market is? Text it.  Or heart-healthy recipes to help those with hypertension eat better? Text it.

Looking to more complex behavior changes, it’s helpful to look first at the population one is targeting, then choose the right technology.  So, iPhone apps that collect mood data for depression, for example, are great for higher-income groups, but they aren’t great for the 60% of patients who don’t have smart phones.  Patient population first; technology solution second.

Lastly, in the past year, there’s been some great data on positive behavior change when patients use texting.  Teenagers take their meds more, recently discharged hospital patients are readmitted far less, and public health compliance soars with texting.  Often, a simple text is all it takes to nudge someone forward.

This is a very hot topic in a very hot space right now.  We have some very smart people working advancing the concept further, and for good reason. We are all patients.

Howard Luks is an orthopedic surgeon who blogs at The Orthopedic Posterous.


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  • MoniqueSerpasPT

    There is a popular book, Nudge: Improving Decisions About Health, Wealth, and Happiness, by Thaler and Sunstein. I’m currently reading it and brings up interesting points about the psychology of our choices and certain strategies to “nudge.”
    I agree with you. “And, from my own personal experience, many post-surgical patients do not follow well described, well articulated, printed, post operative protocols.” These are the patients that usually end up in physical therapy for instance after arthroscopic knee surgery. I find the same with my home exercise programs, despite them being clearly written and illustrated and sometimes even via video! I’ve come to realize that it’s not just that a person needs to be nudged or simply reminded to do something. Many people have very little understanding not just about their bodies and how they work, but the impact of injury or surgery and stages of recovery. I believe this is why certain people do not follow protocols or home exercise programs, because they don’t realize its importance and impact, which is why each of my physical therapy sessions include patient education into why they are doing what I am asking them to and the consequences of not abiding by such recommendations. My coworker receives an email newsletter from his primary care MD that highlights research, explains medical concepts, and encourages healthy behavior. This may be another “low-cost” means to providing the education that our patients need.
    Other healthcare practitioners, could utilize technologies, as you mentioned texting, to encourage good behaviors. When you know someone cares about your behavior and you will suffer consequences as well as disappoint someone else, you’re more likely to follow-through. I get email reminders from my dentist… I have to say they are effective in encouraging me to floss reguarly.

  • Steve Levinson, Ph.D.

    A clinical psychologist, I invented a “gentle nudger” over 25 years ago ( that helps people of all ages actually consistently do what they know they should do. What motivated me was the belief that the human mind is much better at responding to reminders than it is at issuing it’s own. In my opinion, healthcare will take a significant step forward when we fully appreciate that without continuous exposure to the right reminders, most patients are unlikely to make healthy changes in behavior no matter how well we educate them.

  • Jesse Middleton

    Couldn’t agree more. Three of the most powerful things that you can do to help change people’s habits and to get them to make healthier decision are: bring their social circle in (not necessarily Facebook but people they care about), give them helpful nudges to remind them of things they need to do and provide them feedback along the way. These three things work right along with the way the human mind functions.

    -People are social creatures and generally like to be around others similar to them. If your friends take their pills, you’ll take yours.

    -People have a tough enough time remembering a phone number let alone all of their meds, schedules and plans that they need to stick to. Reminding them to do those things goes a long way.

    -Feedback is the only way people will know when they’re doing something right OR wrong. It can be as simple as an email or as powerful as real rewards and gifts.

    It’s tough to find a good blend of all of these but it’s doable (heck, we’re working on it).

  • Erica Holt

    I agree that there is a compelling argument here, and the several studies supporting evidence that text messaging increases medication adherence are worth attention. At the same time, I think we still need to see more causal evidence about whether these new technologies that use the nudge concept to encourage behavior changes actually work. They seem like they would. I’ve heard anecdotal stories from individuals saying a mobile app, for example, has helped them live healthier. But, really, is the evidence to support this there yet? I think we have a long road research ahead of us to know for sure.

  • Howard Luks

    Erica… we certainly do have a long way to go. I’m encouraged by the early research and literature. Look at what folks share on FB. WHy couldn’t a group of total knee patients share their progress and encourage those lagging behind. I see it everyday on a small level in our PT area. Modern day medicine has not been very successful at incenting patients to modify their behavior… perhaps a patients social circles will prove to be a better alternative. Thanks for the other comments too!

  • RJ F

    I think social media can not only help patients modify behavior, but also give medical professionals an additional tool to help treat/coach their patients back to health. With extra support behavior can change for the better.

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