CREATING LASTING BEHAVIOR CHANGE: THE INTERPLAY OF EXTRINSIC AND INTRINSIC MOTIVATION There are two types of motivation: extrinsic (money, praise, trophies,...) and intrinsic (enjoyment, satisfaction, mastery, ) Only intrinsic motivation leads to the long-term, sustainable behavior change needed for improvements in population health. Extrinsic incentives can be useful to encourage the crucial first step towards change. There are specific steps you can take in designing health programs and employee communications to make use of intrinsic motivation, outlined herein. 1
CONTENT Overview...................... 3 Why do we do what we do?........... 4 Where extrinsic motivation fails........ 4 What are intrinsic motivators for healthy behavior?...................... 5 How and when to use intrinsic and extrinsic motivation...................... 7 About the author.................. 7 Further reading................... 8 References..................... 8 OVERVIEW If you ask employee benefits leaders about the greatest challenges they face in improving the health of their population, and their company s bottom line, one factor tends to top that list: engagement. Does any of this sound familiar? We re offering all sorts of great programs, but we simply can t get our employees to sign up. The only way we get anyone to take part in any wellness activities is by paying them. At this rate, we ll be paying more in incentives than we re saving! We see a lot of enthusiasm whenever we start a new program, but everyone seems to lose interest in the blink of an eye. Well, changing your habits, changing your lifestyle is hard - it s easier to reach for that second cookie than commit to a nutritional counseling program. But it s exactly this sort of behavior change that s needed in order to improve population health. And only dramatic improvements in population health will meaningfully bend your cost-curve in the long run: employers are rapidly reaching the end of what they can achieve by shifting costs from health plan to plan member. Luckily, there is growing appreciation for the art and science of encouraging meaningful, lasting behavior change. And a key concept in this effort is the interplay between intrinsic and extrinsic motivation. In the next few pages, we ll talk about the important differences between these types of motivation, when it makes sense to use one or the other, and how you can apply this knowledge. The information is based on our extensive review of the the literature on this topic, and conversations with hundreds of participants in our program for chronic back and joint pain. 2
WHY WE DO WHAT WE DO? There are two fundamental types of human motivation: intrinsic and extrinsic. Extrinsic motivation is the more obvious one. It means doing something for external rewards - such as showing up at work each day because of the paycheck you receive. Other examples are grades, competition, trophies, or praise. Intrinsic motivation means doing something because of an inherent interest in, or enjoyment of the activity. As the name implies, it does not rely on external pressures or rewards. In the context of a health benefits program, extrinsic motivation would be driven by financial incentives or penalties. Intrinsic motivation can only be generated by members understanding and internalizing that they will derive enjoyment and satisfaction from a program. It is of course easier to tell employees they ll receive $100 for completing their HRA, than conveying the more intangible rewards of a healthier lifestyle. Which leads us to two questions: Why don t we just rely on extrinsic motivators, since they re so much simpler? And if we do want to tap into intrinsic motivation, how do we go about that? WHERE EXTRINSIC MOTIVATION FAILS Let s start with the first question. There are some very real downsides to relying on incentives and rewards to drive your members towards certain behaviors. 1. They undermine intrinsic motivation In the short-term, tangible rewards particularly monetary ones undermine motivation for tasks that are intrinsically interesting or rewarding. 1 This effect is often referred to as crowding out. For example, one study found that college students will spontaneously play with interesting puzzles, but once they re paid to solve them, they lose interest in playing for free. 2 This crowding out effect is strongest when external rewards are (a) large, (b) perceived as controlling, (c) contingent on very specific task performance, or (d) associated with surveillance, deadlines or threats. And would it be a stretch to say that avoiding several hundred dollars worth of insurance penalties by completing healthy activities on a checklist would meet all four of these criteria? 2. They lose their effect in the long-term Longer-term, relying on extrinsic motivation can have other consequences. 3 One often needs to increase the size of the rewards (and punishments) over time to maintain the same effect on behavior. And what s more, once the 3
external reward is removed, all motivation is often lost. In one example, day care centers imposed fines on parents for picking up children late. They found that tardiness actually increased, and remained high even after the fines were eliminated. Fines transformed promptness from a moral duty to a market transaction governed by price. 4 Interestingly, there is one exception: symbolic rewards (such as praise or flowers) do not crowd out intrinsic motivation, and may even augment it. WHAT ARE INTRINSIC MOTIVATORS FOR HEALTHY BEHAVIOR? It should be clear by now that we won t be able to drive meaningful and lasting engagement with any healthcare program through financial incentives or penalties alone. But to understand how to tap into intrinsic motivation, let s first dive into motivators that are effective (or not) in the context of healthy behaviors. How about this slogan? Join our diabetes prevention program. You ll get the help you need to achieve a healthier weight, and lower your risk of developing diabetes and other dangerous health conditions in the future. Sounds like something you should want to do, right? Well, as humans we are notoriously poor at making trade-offs between near-term effort and long-term reward - so thinking about our long-term health is not a great motivator. Instead, why not focus on how the extra energy gained from exercise would allow you to be more active with your kids? Or how rewarding it would be to cook a healthy meal for your family? Or how you can make new friends through an exercise class? In general, strong intrinsic motivation for behavior change is generated through the following: 1. Helping identify personal intentions and benefits, i.e. the most relevant near-term outcomes of the new behavior. 2. Providing and reinforcing how-to knowledge, making the change easier. 3. Promoting self-mastery: the satisfaction that comes from taking control of one s life and successfully surmounting a challenge. 4. Fostering a sense of belonging and recognition, through being part of a team, public recognition, or the opportunity to mentor / give back. 5. Harnessing the power of personal, emotional stories - framed in terms of others like you. 4
6. Defining a step-by-step action plan. 7. Allowing participants to make the program their own by providing ideas and solutions - such as recipes for a healthy cook-off. 8. Making the change fun, by introducing humor, gamification, etc. This list is of course not comprehensive, but is a great place to start brainstorming ways to encourage engagement with your employee health programs. Hinge Health routinely activates move than half of the affected memberbase after a first marketing campaign. And weekly engagement is at 90%+ levels. This is in significant part due to the focus of our communications on what we know intrinsically motivates our users. The three most important motivators for our participants are: What motivates our users to dedicate 12 weeks to Hinge Health s programs for back and joint pain? THEY WANT TO GET BACK TO THE ACTIVITIES THEY LOVE I have had a big reduction in knee pain and have gotten back to doing the things I love: hiking and dancing! For over a year, I had thought that I would never return to them because my knee was so messed up. I am so happy now! Hiked Uneva peak this week with NO knee pain. You all probably feel similar results. Don t quit! THEY WANT TO AVOID THE PAIN AND RISKS OF SURGERY My knee hurts all the time and I ve been told by my knee doctor that I will eventually need a knee replacement and I m trying to delay it as long as possible. My activity level is increased, I m feeling stronger. I am hopeful, for the first time in a long time, that I have options other than surgery to stay active and fit. THEY WANT SUPPORT & ACCOUNTABILITY TO HELP THEM HELP THEMSELVES I absolutely recommend it. It s a great way to learn how easy it is to take care of yourself. I am very thankful for this program. Having to be accountable is quite a motivation. 5
HOW AND WHEN TO USE INTRINSIC AND EXTRINSIC MOTIVATION At this point, you might be thinking that intrinsic is always preferable to extrinsic motivation. Certainly, communcation and design of health programs can be improved using the concepts outlined above, yielding dramatically higer takeup and engagement. However, the most powerful strategies use both. Intrinsic motivation, by its nature, arises naturally, from inside. It is far from trivial to artificially create it - and it often requires time and multiple interactions to take hold. Extrinsic incentives can have a powerful effect when used to encourage a first step towards a new healthy behavior, especially if the rewards of the program might be too abstract or distant. As a parting thought, we want to leave you with a few questions to ponder regarding how to apply the information from this article: Am I over-reliant on incentives and penalties to drive behavior change? Do I understand the intrinsic motivations that drive my members to sign up for, and engage with my existing health programs? Are my programs explicitly designed with these intrinsic motivations in mind? Do I have an effective strategy for weaning my members off extrinsic motivators after they start a program? ABOUT THE AUTHOR Gabriel Mecklenburg is the co-founder and Head of Care Pathways at Hinge Health. He has been passionate about musculoskeletal health ever since a ligament tear ended his days on the Judo mat. He graduated top of his class in Materials Science at the University of Cambridge, and went on to research regenerative medicine at Imperial College London, focusing on shoulder injuries. If you are interested in learning more about Hinge Health s digital programs for musculoskeletal health, and how we reduce surgery utilization by more than 50%, get in touch at gabriel@hingehealth.com. 6
FURTHER READING The Art of Health Promotion: Practical information to make programs more effective Considers motivation from a wellness perspective, with many practical examples. A very useful, albeit lengthy, article. http://www.chapmaninstitute.com/articles/03_tahp_26(3)_intrinsic_motivation.pdf Gamification: Intrinsic Motivation for Lasting Engagement Provides a good introduction to the two types of motivation and considers them from the point of view of gamification (a typical source of extrinsic motivation). It argues that intrinsic / extrinsic motivation are co-dependent on one another, meaning gamification can be used to drive intrinsic motivation. https://elearningindustry.com/gamification-intrinsic-motivation-lasting-engagement REFERENCES 1. Deci, EL et al., A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation., Psychol Bull. 1999 Nov;125(6):627-68; discussion 692-700. 2. Deci, EL, Effects of externally mediated rewards on intrinsic motivation, Journal of Personality and Social Psychology, Vol 18(1), Apr 1971, 105-115. 3. Matt DeLong and Dale Winter, Learning to Teaching and Teaching to Learn Mathematics: Resources for Professional Development, Mathematical Association of America, 2002, page 168. 4. Gneezy U & Rustichini A, A Fine is a Price, The Journal of Legal Studies 2000 29:1, 1-17 7