Moving Beyond Individual to Collective Responsibility for Behavior Change

The search for the “American dream” compelled my parents to leave their homeland to come to the United States with few resources, money or support. Having left behind the comforts of home complete with the richness of language, family, friends, community, culture and a way of life, they sought the promise of a better tomorrow. As a first generation American, I have greatly benefited from their immigration in innumerable ways; yet, I have a more nuanced relationship with the concept of the “American dream.”

The quintessential American mantra of “you can be anything you want to be” implies that success is achieved only through hard work, determination and persistence- all factors that are perceived to be largely in the domain of the individual. The natural consequence of this line of reasoning is a system of meritocracy whereby individuals advance in society based on their merits irrespective of other influences. Though a debate on the utility of the framework of meritocracy itself is outside the scope of this current discussion, the underlying assumptions that individuals are on an equal, fair playing field with the ability to overcome any circumstance have far reaching implications¹.

In healthcare, the ideology of the American dream gets translated into viewing health through the lens of individual actions, choices and behaviors with typically no thought to the broader social determinants of health (SDOH) that limit human flourishing. Patients are seen as individual actors with complete autonomy and ability to simply change the choices that they make. Given that “unhealthy behaviors” account for about 40% of premature deaths in the United States, efforts to advocate for and support healthy behaviors remain one of the most important and commonly used tool in the healthcare provider toolkit².

Yet, anyone who has ever struggled to lose weight knows that behavior change is incredibly difficult. More than the result of a simple set of choices anchored in deep motivation, we are enmeshed in a complex web of daily landmines that can derail our weight loss journey every step of the way. Whether it be the candy at the checkout isle or the well-meaning colleague who brings delicious baked goods to work, the architecture of our natural, built and social environments greatly influences the choices we make.  Compounding life stressors deplete the reserves of our will until we succumb to momentary delights. To an outside observer, our choices can appear counterintuitive to our efforts or outright bizarre. Human behavior is much more complex than any one individual binary choice. The contribution of behavioral economics and social psychology has shed light on the idiosyncrasies of the human condition in “nudging” towards behavior change, explaining seemingly irrational behavior and illuminating the role of social networks^3,4.

Though a multitude of studies have shown successful interventions in the space of initiating behavior change from smoking cessation to obesity^5,6, strategies to sustain ongoing behavior change are much more difficult and nuanced². Dr. Mark Bouton in a 2014 article highlighted the various difficulties in sustaining behavior change as 70% of individuals who quit an unhealthy behavior eventually succumb to it again. Of note, he highlights two key features of behavior change that make adherence so problematic: the new behavior does not eliminate the old behavior and behavior is largely context-dependent.  Such conditions can lead to lapses and relapses causing reevaluation of the concept of behavior change into a long and evolving process and perhaps outside the traditional confines of short-term interventions².

It is precisely the conditions under which people live, work, play and age that determine our contexts and sculpt the kind of choices we have and are encouraged to make in innumerable conscious and unconscious ways. In order to support the challenging task of individual behavior change, we must also advocate for addressing the “causes of the causes” and facilitating the structural changes to create conditions for their success. The well-known successful interventions in the realms of seat belt laws and regulations on the smoking industry have yielded in significant reductions in car accident fatalities and rates of smoking respectively^7,8.

When we start shifting our perspective about behavior change from merely individual responsibility to greater collective responsibility, we can also better see the systems in place that allow them to continue and create new ones that take us beyond the individual. Perhaps this requires a fundamental evolution of the “American Dream” to integrate how we are all connected and bound to a social contract to lift each other up and create the conditions to ensure success for all.

-Premal Patel, MD Community of Practice Member

Dr. Premal Patel is a board-certified Physician and an Associate Professor in the Department of Internal Medicine. She also serves as the Associate Director of the Global Health Education Program at UTMB and is co-coordinator of the Global Health Inter-Professional Core Course.

References:

1. McNamee S, Miller R. 2014. The Meritocracy Myth. Lanham, Md. Rowman & Littlefield Pub.
2. Bouton M, Why behavior change is difficult to sustain, Prev Med. 2014 Nov; 0:29-36.
3. Tagliabue M, Squatrito V, Presti G. Models of Cognition and Their Applications in Behavioral Economics: A Conceptual Framework for NudgingDerived From BehaviorAnalysis and Relational Frame Theory Front Psychol. 2019; 10: 2418. Published online 2019 Nov 1. doi: 10.3389/fpsyg.2019.02418.
4. Leahey T et al. Social networks and social norms are associated with obesity treatment outcomes. Obesity (Silver Spring). 2015 Aug; 23(8): 1550–1554.Published online 2015 Jul 7. doi: 10.1002/oby.21074.
5. Prestwich A et al. How can smoking cessation be induced before surgery? A systematic review and meta-analysis of behavior change techniques and other intervention characteristics. Front Psychol. 2017 Jun 7:8:915.
6. Texiera P et al. Successful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators. Front Psychol. 2017; 8: 915.Published online 2017 Jun 7. doi: 10.3389/fpsyg.2017.00915.
7. Shults R et al. Primary enforcement seat belt laws are effective even in the face of rising belt use rates. Accid Anal Prev. 2004. May;36(3):491-3.
8. Paoletti L et al. Current status of tobacco policy and control. J Thorac Imaging. 2012. Jul; 27(4):213-9.