What Works Best? Knowledge, Skills, Motivation, and Opportunity

At least once a month someone asks me, “What Works Best...? What Makes a Health Promotion Program Successful in Improving Health Behaviors?”

I sometimes respond with a rapid-fire lecture on the large-scale studies linking specific behaviors to excess morbidity and premature mortality, the impressive literature linking medical costs to lifestyle behaviors, the hundreds of studies that show programs do improve health behaviors or the dozens of studies that show programs save money.

When I do that, the response lately has been: “That’s interesting, but . . . it’s not really what I asked. What works? What makes people change behavior?”

The pace of my speech slows down, and I usually talk about the importance of theory-driven programs that incorporate stages of motivational readiness to change, setting goals, enhancing self efficacy, engaging social support, providing incentives to recruit people into programs, tailoring materials and programs to individual learning styles, education, schedules, age, gender and other factors, as well as efforts to shape cultural norms to support positive behaviors, and policies and facilities to reinforce them. I often refer people to a benchmarking study¹ that found the best programs link program goals to organization goals, have strong budgets, strong management support, good communication efforts, good evaluation components, incentives, and culture change efforts. I also talk about the importance of programs to enhance awareness, facilitate behavior change, and create supportive environments², but reluctantly admit we really don’t have much research to support the importance of these factors.

The response to this answer is usually: “You really don’t have research to show what works best? Geez! That’s too complicated anyway! I need a simple framework to plan my program. What do you suggest?” To which I respond:

What it boils down to is knowledge, skills, motivation, and opportunity.

We need to provide knowledge on the impact of behaviors like smoking, physical activity, nutrition, stress, and other behaviors on health, and specific guidelines on how to exercise, prepare healthy foods, manage stress, quit smoking, do appropriate medical self care, etc. As a profession we are fairly proficient at education, but it is the least important of the four factors. Most people know what’s good for them in general terms. If education were enough, we would have few lifestyle related health problems.

Much more important than knowledge, we need to teach people skills. This includes specific techniques on how to exercise properly, prepare healthy foods, manage stress, quit smoking, do appropriate medical self care, etc. It also includes: training people in the skills they need integrates healthy lifestyle practices into their lives, specific techniques for each behavioral area, and problem solving skills to overcome barriers in opportunities; but for them to be ready to learn these skills, they need to be motivated.

So, we also need to help people become motivated to be physically active, not smoke, eat well, manage stress, etc. Providing incentives, tailoring programs, and making programs fun are all important, but to be most successful, we need to better understand the underlying passions, long- term goals, and current priorities in a person’s life, and draw the connection between these and the behaviors we are advocating. If there is no connection, we probably will not be able to stimulate the motivation. If there is a clear connection, the motivation will be enough to make most people discover what they need to know and figure out how to incorporate healthy behaviors into their lives.

Finally, we need to help people have the opportunity to practice a healthy lifestyle. This includes having access to fresh fruits, vegetables, grains, legumes and other healthy foods, as well as safe and inviting places to walk, run, swim, lift weights, do yoga, aerobics, and other activities. It also includes helping them carve out protected time to do these things, and being supported by family, organizational and community norms that reinforce them. In some cases, it means escaping from stressful situations that consume them and prevent them from focusing on anything else. An abundance of opportunity may cancel the need for education and motivation. An absence of opportunity will probably prevent even the most knowledgeable and motivated person from practicing a healthy lifestyle.

References

1. O'Donnell M, Bishop, C, Kaplan, K. Benchmarking Best Practices in Workplace Health Promotion. The Art of Health Promotion , 1997;1:1

2. O’Donnell, M. Definition of health promotion: Part III: expanding the definition. Am J Health Prom. 1989;3:5.
   
   

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion