Using Health Information Technology to Change How Someone Defines Themself

Long-term behavior change seems to require intrinsic motivation. If we in healthcare can move from “telling” patients what to do and move toward helping patients see how their behaviors reinforce or challenge their identify, then the odds of sustaining healthful behaviors may increase. Charles Duhigg, James Clear and Mark Manson (“What is the pain you want to sustain?”) all describe how habits are formed and provide suggestions on ways to “harden” those habits over time. But there may be another avenue to engage individuals around health behavior change.

Deci and Ryan’s self-determination theory suggests four flavors of extrinsic motivation distinct from intrinsic motivation. External regulation is behavior driven by someone else providing rewards and punishments. Introjected regulation is behavior focused on how others perceive the individual (e.g., pride, guilt). Identified regulation includes behaviors recognized and valued by the individual. Integrated regulation includes behaviors that are consistent with one’s personal values and beliefs. The researchers define intrinsic motivation as behaviors that support increased knowledge, accomplishment and stimulation.

Instead of focusing on cues and triggers and pain, maybe a paradigm focused on continuous learning (“sucking less”) might be easier to accept. Watching my kids mimic my behaviors forced me to reconsider what choices I routinely make. My children will probably not provide me with explicit praise for being a “good dad,” but my own identity is strongly tied to learning from my mistakes. I believe that I have the knowledge, skills and attitude to better a little better every week. Since I’m completing with last week’s me, the small improvements I am making are enough to keep me motivated to do more. Just as important, my kids provide nearly continuous feedback.

Amy Morin suggests that intrinsic motivation can be increased by 1) doing challenging things that offer some performance feedback, 2) tapping into the individual’s natural curiosity, 3) exercising some degree of control over the situation, 4) some types of social engagement through cooperation or competition and 5) recognition by others. When we in healthcare talk about patient’s controlling the situation, the conversations seem to center around dietary habits, physical activity, safe sexual practices, medication adherence and drug use (tobacco, alcohol and others). Many of these behaviors may be linked to cues and rewards. But if the individual is suppressing an urge to do a particular behavior, that individual will probably revert to that behavior in times of stress.

Brent Smith and his colleagues at the University of Arkansas have formulated a theory around identify convergence in the context of radicalized youth and terrorism. Individuals perform identity work, actions that create, present and sustain a specific identity. The actions include things an individual says or does, how they look and with whom they associate. Members of a group then uses different types of framing to address an issue together. Motivational framing asks “Why should we address this issue?” Diagnostic framing asks “who’s at fault?” Prognostic framing asks “what needs to be done?”

Although social media has transformed how we organize as groups as well as how we see ourselves. Unfortunately, the literature on changing one’s identity through online interactions is mostly focused on the effects of pornography, body dysmorphia and violence. Jim Taylor argues that self-identity is formed through both self-awareness (observing and evaluating past experience, current needs and future goals) and feedback from the social and cultural environment where we live. The rise of social media has placed more emphasis on approval from individuals (or bots) with no connection to an individual’s local social and cultural environment, altering self-identity without feedback loops available in the offline world.

Health information technology may be able to move individuals with introjected and identified regulation toward integrated regulation or intrinsic motivation by providing a forum to both perform identity work for others to see and allow for social interaction (cooperation [e.g., group problem-solving, mentoring], competition). Although promoting one’s personal brand is a large part of social media (e.g., I am publishing this on my own website), I am not convinced that people will consider promoting the adoption of new health behaviors as a way to gain social status. We in the health information technology community could do more to identify what type of motivation an individual might be using support their existing health behaviors and highlighting opportunities to shift those behaviors to better support future goals. In an effort to “suck less,” creating a series of achievable behaviors may be more important than emphasizing the aspirational goal (e.g., “I can jog a half-mile further than last week” instead of “I will run a marathon.”). Ideally, adopting new behaviors may support a new identity with internally-focused motivations to help sustain the behaviors long-term.

Although gamification has received a lot of attention in helping promote behavior change, I am not sure the habits one aquires through a “gamified” experience with external rewards easily convert into behavior based on intrinsic motivation. One recent randomized trial using behaviorally designed gamification techniques among overweight and obese adults showed a small increase in the number of steps taken, but the gains decreased after the intervention was stopped. Focusing exclusively on information technology to drive changes in identity and subsequent long-term behavior change may introduce other challenges. Online identities, and associated identity work, may be completely fabricated. If poorly calibrated, suggested identities and their supporting behaviors may actually demotivate individuals. Online communities may need trusted moderators to reduce the risk of misinformation being spread. Health information technology is more likely to support changes in self-identity if the online content and interactions happen within a local environmental context that support that change in self-identity.

Long-term behavior change is necessary to reduce the incidence and severity of non-communicable diseases. The healthcare system is not currently structured to support long-term behavior change through our fee-for-service or value-based payment models. External rewards and penalties may not support an individual’s own efforts to transform their identity to one that more readily supports healthy behaviors. Health information technology may help increase intrinsic motivation to change behavior if tactics are used to assess an invidual’s health behavior-related identity and behaviors that reinforce that identity. I believe the entities that can create a series of achievable shifts in identity with associated behaviors will be in a better position to support individuals interested in improving their health.