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Forget about health, I take medicine because of the lottery

Image by Laurynas Mereckas

What could be more important than... our lives?

Yet, amazingly we often see examples of people putting themselves in danger:

  • We have doctors who are morbidly obese

  • People who do not wear seat belts despite cars being installed with reminder beepers

  • And most recently, even with more than 15 million infected and close to 625 thousand casualties due to Covid-19, people still reject keep safe distancing and wearing masks, even if it is meant to save their lives. Read more about this here. 

In addressing such issues, our normal response is to tell people what the right thing to do is. But this is clearly not an effective strategy. Do people really not know that putting on a seatbelt or not eating too much is bad for them? We know what the right thing to do is. We just can't bring ourselves to do it. 


So, changing the behaviour of people has to extend beyond giving them information. Instead, we have to explore creative and sometimes counter-intuitive solutions that get people to do what they otherwise wouldn't.  


These could mean reducing the friction of taking action (for example, just pressing one button, or free delivery, or automation where you only need to decide once) or increasing the attractiveness of doing something (for example, putting in incentives or coupling the action that needs to be taken with another action that people enjoy).  


And one area where a large amount of creativity has been generated is how we can get people to take their medication on time.  


Yes. Even though life is precious, and medication saves lives,
people still need to be convinced to take it on time. 


Psychologists have worked with medical teams to design all sorts of interventions - rewards, fines, reminders, notifying loved ones that you have not taken your meds.. everything you can think of.


2 of the most prominent psychologists in this area - Kevin Volpp and George Lowenstein - went one step further. They were working with patients who had previously suffered from a stroke. These patients had to take a medication - warfarin - on a strict schedule. 


Volpp and Lowenstein conducted two pilot studies to try and improve warfarin adherence.. with the introduction of.... a lottery.

Patients were given their pills in an automated pill-box, which enters their name into a lottery if it is opened at the right time each day. 


Did this work? 


In the first pilot, the adherence rate of taking the pills went up from 65% to 87.8%. Btw, it's also worth noting that once the lottery experiment ended, adherence rates fell to 58% (lower than original) - we will come back to this point later. On top of this, the number of incorrect pills taken, traditionally at about 22% dropped to just 2.3%

In the second pilot, the results were replicated. Adherence rates of the second group went up from just 35% to 59.6%. The proportion of incorrect pills taken fell to just 1.6%. You can read the full paper here


Why does this happen? Why do we need rewards to save our own lives? And why do lotteries work so well?

The answers come in 2 particular features of our brains:

  1. We value the short term over the long term.

    • A simple and classic example: say you have a craving for chocolate. And someone offers you: would you like half a bar of chocolate now or 1 bar of chocolate in one week's time? Or substitute chocolate for any other reward. What comes immediately feels more valuable. 

    • In much the same way, health is long term. We don't become unhealthy overnight. Even for stroke patients, a relapse is very unlikely just because the patient misses one or two days of medication. Conversely, good health is difficult to observe, if at all. We don't feel the value of good health because we have made a correct decision today to take our medication on time.

    • There is actually neurobiological wiring behind this. Our brain's reward system does support short-term pleasure more. If you're interested, you can check out our page on dopamine (dopamine - which is often misrepresented by psychologists and thought leaders in popular media)

  2. We try to avoid pain because, in the past, it has a higher chance of causing us harm.

    • Again, it's not difficult to identify examples of this in real life:

      • Diet starts tomorrow!

      • I really want to work out but I'm just really tired today; I promise to make up for it tomorrow

      • I'll have that difficult conversation with this other person tomorrow. I can't do it today

    • For much of human existence, anything painful usually means danger. Think about your ancestors in the past - pain from a plant, an animal, a fall, a fight, a climb - could all easily lead to their demise. Over many cycles of evolution, our brains became wired to avoid pain to ensure our survival. Today, the nature of pain has shifted considerably away from physical to mental pain - very few things threaten our survival these days, but the wiring of our brains has already been set, as seen in the examples above. If you're interested, you can check out our chapter on pain here. 

    • Taking medication contains elements of pain. At a simpler level, it is the pain of inconvenience, of constantly having to worry about taking medication on time; at a deeper level, it is the pain of being reminded you are not well, and you need this schedule of drugs to keep you ticking.

This is where the lottery system comes in. It provides an immediate reward (and if you read the chapter on dopamine, it provides an uncertain reward, which is even more effective). And this reward causes us to forget the pain patients might experience otherwise. 

A similar and fascinating example happened with a group of Hepatitis C patients, who had to take mediation which caused considerable discomfort, but which would save their lives. Only 1 patient managed to finish his course of medication, and he did so by introducing his own reward on the days he had to inject himself. Read more here.

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