What Mary Poppins teaches us about behavioural economics 

In every job that must be done
There is an element of fun
You find the fun and... snap!
The job's a game
And every task you undertake
Becomes a piece of cake
A lark! A spree! It's very clear to see that
A spoonful of sugar helps the medicine go down
The medicine go down
The medicine go down
Just a spoonful of sugar helps the medicine go down
In a most delightful way
Mary Poppins

The lyrics of A Spoonful of Sugar, written by brothers Richard and Robert Sherman for the 1964 Disney classic Mary Poppins, contains some great insight into human nature.

Richard Thaler, the Nobel prize winning behavioral economist, says one of the most important things he’s learned is “if you want people to do something, make it easy”. And we would suggest, as a close second, if you want someone to do something, add some pleasure in the present.

The Sherman brothers, and Mary Poppins, knew this. A Spoonful of Sugar advocates the importance of fun and pleasure in general, in encouraging people to do things that, while offering future benefits, feel unpleasant in the present.

The areas of human nature this touches upon are known by behavioural scientists as hedonic utility (the pleasurable reward that comes from an action or choice) and hyperbolic discounting (the innate tendency of humans to be swayed more by a smaller reward or consequence in the present than by a larger one in the future). In general, humans are intuitively drawn more to actions that give them pleasure now, than those that offer functional benefits in the long term – even if they know the longer term gain would have greater value.

So what has all this to do with health? The answer is that health communication – whether dispensed by individual healthcare providers, governments or even pharmaceutical companies, has traditionally preferred narratives that seem persuasive from a rational, long-term perspective: “If you quit smoking now you might not lose a leg in 30 years’ time” or “if you consume less sugar you won’t become fat and diabetic”.

Focusing on important outcomes in the future — essentially asking people to give up something pleasurable or start doing something they find difficult now, for the gain of a longer, healthier life – sounds good. As the strategic approach that has until now been adopted universally in health communication, it has had some notable successes. But are there more efficient and effective ways to encourage healthier lifestyles using strategies based on more immediate benefits that are both rewarding and pleasurable?

Examples of this exist already. Do we really brush our teeth every morning in order to avoid losing them in 20 years’ time? And arguably, the reduction in smoking in the last four decades, and the associated 40% reduction in fatal heart attacks, owes as much to feeling bad with a cigarette as a result of the change in attitudes that have stigmatised smoking and smelling of smoke, and which have banished smokers to unpleasant restricted areas, as it does to the long-term prospects of serious illness and death.

And so, in conceiving and designing strategies for better population health, focus on the long-term ‘does good’ and on the immediate ‘feels good’ are not separate and mutually exclusive, and the ideal would be models that provide immediate rewards for healthier actions – making it easy, pleasurable or even delightful. Here we’ve adapted a 2x2 quadrant frequently used by behavioural scientists to illustrate this.

Traditionally, conversations about health have focused on the bottom-left quadrant, about doing good in the long term.

Many behavioural scientists would agree with Mary Poppins and suggest that in most cases — even ones where outcomes relate to something as serious as health, life and death — you will do better in your efforts to change health behaviours if your interventions are designed with the top-right quadrant in mind. Indeed most healthcare providers prepared to step back from their ingrained attitudes and routines would also agree with Ms Poppins.

So, following her example, how can we add a little more of the top-right box to healthcare interventions? And - other than the recent reemergence of Mary Poppins - why is now the time? Until now, traditional attitudes and models of care delivery in the old, analogue world had no tools to help deliver - and therefore no reason to even consider - whether ‘feel good’ experiences can be delivered at the right time to shape behaviour. The timing is, of course, critical. A pat on the back from your cardiologist at your six months post-heart attack checkup for keeping your cholesterol levels down is welcome, and pleasurable. But it is so disjunct from the actual behaviours (exercise, healthy diet, taking your statins) that got you there, that this dopaminergic moment may do little to reinforce those behaviours.

Technology – particularly mobile devices and wearables – can make these reinforcements timely. Timely in terms of getting the reward with the right temporal proximity, and also timely in terms of prompting the behaviour at the optimal time for better health outcomes – thereby setting up a behaviour-reward virtuous circle.

Examples of this include widely available and adopted apps as well as smartphone and peripheral sensors to prompt and reward activity, sleep and nutrition. The reward component of many existing use cases has tended to be simply information feedback to the user, and therefore more ‘do good’ than ‘feel good’ - and therefore open to the criticism of being adopted least by those who need to change their behaviour the most. But there are recent encouraging examples of successful hedonic virtuous circles of the sort that could become embedded in the fabric of healthcare. Discovery Health, an international health insurance company, are subsidising gym memberships, and recently reported on more than 400,000 of their insured patients across three countries who received Apple Watches at minimal cost which they could keep if their step count – also monitored centrally - achieved specified thresholds. The result of the reinforcement and reward was a 30% increase activity, importantly even greater (50%) in those patients at highest risk.

Improving levels of physical activity is known to improve health outcomes. Indeed, we need to make sure that all interventions using hedonic levers are designed to change behaviour in ways that have been proven to improve health and outcomes.

For the first time in human history, infections do not head the World Health Organization’s list of the biggest killers in the world. Infection has been surpassed by long-term conditions that include diabetes, cardiovascular, airways and kidney disease and mental illness. The growing burden of these diseases, which is crippling healthcare systems worldwide, is paralleled by an acceleration in growth of health-tech.

We therefore have both the motivation and the means for developing innovative models of care that will both improve the wellbeing of the population and the sustainability of their healthcare systems. But to-date, innovation in disease management has tended to be a series of small increments of ever-diminishing residual gains in outcome through the increasingly costly refinement of diagnosis and treatment. This cannot be the route to having the greatest mass impact on global health. We have to ask ourselves whether the goal of innovation is increasingly expensive healthcare for the few, or increasingly cost-effective healthcare for the many?

The urgent health challenges and fast-emerging digital health technologies are prompting a global rethink about how healthcare is organised and delivered. Could they herald a real and sustainable means of enabling effective large-scale disease prevention programmes? Although there have been some successes in long-term condition prevention, impact on public health will require innovation beyond the technological. The current obesity-diabetes global epidemic is not surprising given the primitive drive of humans to crave carbohydrates and to consume as much of this once-scarce resource when available. We surely need to address this problem at a more fundamental level than legislation by governments to reduce the sugar content in foods.

Against this background, we need to consider just how we can harness the power of digital health technologies for promoting healthy behaviour change. Although this may feel a vain hope, the worldwide craze for Pokémon Go a couple of years ago increased exercise levels for players, with many reports of sedentary people taking on unaccustomed levels of walking, resulting in significant weight loss. Emerging digital technologies can engage the previously unengagable in healthy pursuits and can encourage both unhealthy people and patients alike as partners who win from their use, The goal has to be to create - as behavioural economist Dan Ariely says - the desire to do the right thing, even if sometimes for the wrong reasons.

Health data have traditionally been the reserve of the professional in the patriarchal doctor-knows-best systems of care that perpetuate patients’ helplessness and dependency. Timely feedback and hedonic encouragement represents a unified solution to drive the changes in attitudes and behaviour, encouraged and supported by technologies that are appealing and rewarding of wellness.

And so it is not merely a magical Mary Poppins fantasy to anticipate a virtuous cycle of innovation for better and more cost-effective healthcare for the many, driven by the hedonic reward that developers, behavioral scientists and healthcare professionals can get from the excitement and creativity of making health fun. A spoonful of sugar can make the medicine go down, in a most delightful way… for all concerned.