Incentive to Fail

CHICAGO -- College health officials who rely on incentives to promote healthy behavior among students got a rude (but good-humored) awakening here Tuesday morning during the keynote address of the American College Health Association's annual convention.

Steven Lux, chair of the program planning committee and health educator at Northern Illinois University, said he wanted a speaker "who wouldn't preach to the choir" -- and he definitely got it.

"We all use incentives," Lux said, whether to encourage students to make healthier choices or simply to get them to show up for an appointment. "Sometimes they work, sometimes not so much."

In fact, if one's definition of effectiveness is long-term change, incentives don't work at all, argued Alfie Kohn, a writer and speaker on human behavior, education and parenting.

"To be clear, punishments and rewards can buy one thing and one thing only, which is temporary compliance," Kohn said. "Punishments and rewards, threats and bribes, carrots and sticks are not opposites, they're two sides of the same coin. And that coin doesn't buy very much, as it turns out, when you look at real-life experiences." Data show that rewards are often not merely ineffective, Kohn said, but counterproductive.

Given that pretty much every health center uses incentives in one way or another (think free pizza for filling out a questionnaire, or university swag for sitting in on a lecture), Kohn's point was a salient one.

Kohn cited study after study showing that people -- be they students taking an exam for a grade or smokers trying to quit the habit -- are less committed to the task at hand when they're being "bribed," more likely to choose the easiest rather than most fulfilling route to completion, and thus more likely to give up on the task once the reward stops coming.

In one study, students who received fear-inducing, borderline-sensational pamphlets on the consequences of not getting tetanus shots were no more likely to show up for appointments than were their peers who got more basic, informative literature. In another observing kids who had to color with crayons before they were allowed to use markers, and vice versa, students were less invested in and satisfied with the first coloring tool, regardless of which it was. And in "just about every study that's been done in the last 100 years," Kohn said, students who are told they'll be graded on any given assignment perform worse than their peers who aren't graded. (Kohn is a known critic of a test-centric education system.)

This idea is in no way exclusive to college students, but may be particularly essential for them, Kohn suggested. Students -- most of whom are between 18 and 29 years old, the time when most weight gain occurs --are still more likely to binge drink and gain weight than are same-aged people who are not in college. They're prone to numerous other problems such as anxiety, depression, poor sexual health and risk of suicide. "Not to mention," Kohn said, "that sort of barely post-adolescence sense of invincibility that makes your job kind of challenging."

But that free pizza party for the residence hall in which the most students participate in a health promotion program, while briefly satiating their appetite, sends a message that investing in one's health is something they don't want to do. It also is in essence a control grab -- and as Kohn said, nobody wants to be controlled less than college students.

Kohn's "interesting" take on the topic illustrates the importance of a student's personal commitment to change -- and the role of health professionals in helping them, Anita Barkin, president of ACHA and director of health services at Carnegie Mellon University, said in an interview after the address.

To move away from an incentives-based system "is going to take considerable recrafting of the ways we work with students," Barkin said. "They have to be the person who's driving the change."

Which is exactly what Kohn wants.

"When you're talking about changing students' -- or anyone's -- behavior, you are in effect accepting the core premise of behaviorism: that the only thing that's real is what you can see and measure," Kohn said. "The question isn't, 'How do we help young adults stop smoking or use contraception?' The only question is, 'How do we help these people lead healthy and satisfying lives?' That's a tall order, but you can't ignore it and just try to change their eating behavior. No wondering it doesn't work -- you're missing the point."

It's a tall order because the issue is complex. Unhealthy behaviors are usually coping mechanisms for some loss, fear, or other deeper, internal struggle. And external motivators in the form of rewards and threats are negatively correlated with intrinsic motivation -- the kind of commitment that results in actual long-term improvement. Further, one cannot ignore the critical aspect of the environment in which college students live today: one flush with alcohol, fast food in the student centers, unlimited buffets in the dorms and pressure to excel academically and socially.

If they're to incite true change in students, college health officials must understand all that. Which means relating to and working with students on a personal level (studies show relationships and peer behavior are powerful drivers of change, good and bad), which in turn means putting the students' own progress -- not some incentive or arbitrary guidelines -- at the center of intervention programs.

"Doing things to people, including students, can never be as effective as working with them, but all incentives are by definition a version of 'doing to.' The focus can't just be on the behaviors; it has to be on the needs and reasons and motives and perspectives of the people engaging in the narratives," Kohn said. "That's the only way that points to a successful effort to help them become a more fulfilled, happy population."

Kohn criticized the professionals in all fields who, upon realizing their incentives aren't producing the desired results, assume it must be a problem with implementation, not that it's the idea itself that's flawed. But after Kohn's speech, ACHA President-Elect Jennifer Haubenreiser, who is also director of health promotion at Montana State University, suggested that mindset might not prevail.

"What I love most about this field is we are never afraid to challenge our assumptions," Haubenreiser said. "This is how we grow."