Improving health requires behavior change. But whose behavior needs to change?

Person looking at a cloud of smoke through a magnifying glass. Photo by Saffu on Unsplash

I recently attended a conference on health experience design and was turned off by the ways in which several presenters and workshop speakers framed the role of behavioral design to improve health outcomes. Over and over, I heard people say things along the lines of, “we designed a solution to end [insert person/community]’s poor health (e.g. diabetes, obesity) by creating new ways to change their behaviors.”

I heard speakers state that we need to see people as people, and not problems. At the same time, using design to change other people’s behavior implies, at least to me, that the designers are indeed viewing people as problems (or at least as people with problematic qualities.)

A stop sign. Photo by Michael Mroczek on Unsplash

I saw and heard a number of assumptions:

• There are clear-cut conceptions of what “good health” looks like in comparison to “poor health”;
• Individual people with poor health have problematic behaviors;
• Designers* need to design “solutions” to change the behaviors of people whom they deem to have poor health;
• Designers* are not the ones with the problematic behaviors;
• Individuals are responsible for their health outcomes, and systems of power (in which we all play a part) have no place in the design equation

(*I’m using the term “designers” to refer to people who have decision-making power over others — and social constructs including racism, classism, ableism, and elitism often reinforce this power)

Add race, class, and other identities into the equation, and very quickly we see a group of mostly highly professionalized, highly educated white folks in positions of leadership within their fields talking about how they “disrupt” health and healthcare by creating “innovative” “solutions” to what they deem to be problematic “behaviors” of people (“patients,” “users,” “consumers”) they supposedly serve (does this ring of paternalism and savior complex to anyone else?) Not once do we hear people in this group examine the environments in which these behaviors happen, nor do we hear people in this group examining how their own behaviors create and sustain what they consider to be problematic behaviors in others.

A variety of colorful pills strewn on a surface. Photo from freestocks.org via Unsplash

Instead of framing the discourse on changing the behavior of others, why aren’t people with power, access, and influence talking about changing their own? What if people working within healthcare thought about changing their own behaviors and attitudes first? Questions to work with include:

• Who is in positions of leadership and why? What do these people look like? To what extent do they reflect the rest of the institution and the people the institution they interact with?
• Who has platforms to speak publicly? Why?
• Who sets organizational priorities and agendas that impact other people? Why?
• Who is heard? Why?
• What language does one use to talk about one’s work? To talk about one’s relationship to other people within one’s work? Who and what does one “serve”?
• Who defines what good health looks like? Who defines what poor health looks like?
• Who benefits from health inequities? Who benefits from people having poor health?
• What are one’s assumptions? What are one’s blindspots? What is one not seeing, and what is one not talking about? What ideas, beliefs or actions are in disguise? What is one avoiding?
• What kind of language does use? How does power and agency show up in the language one uses?

If we’re serious about social impact, or equity, or justice, we must recognize, acknowledge, and confront the pervasive ways in which many benefit from socially constructed, institutionally validated forms of power, especially whiteness. In the case of race, this has less to do with whether one is white, and more to do with the complex ways in which one experiences white privilege (for me, this includes unlearning the ways in which Japanese culture and communities aspire to whiteness.) It also looks like examining the ways in which we benefit from the interconnected layers and systems of power just as much, if not more than, focusing on how other people are at disadvantages.

Image of a microscope. Photo by Paweł Czerwiński on Unsplash

It’s problematic that many social-impact-oriented initiatives and institutions focus on addressing (or worse, solving) “underserved,” “under-resourced,” “under-achieving,” and “disadvantaged” communities without examining the people and institutions who benefit from inequity. Why, for example, don’t we ever put “over-served,” “over-resourced,” or “over-advantaged” communities under the social impact microscope? Working for equity has to happen from all sides, and it’s especially crucial to constantly, individually challenge the people, practices, policies, and beliefs — the designs — that deeply normalize whiteness.

We like to think that we are designing with people and not for people. But, like striving beyond equity and towards liberation — we’re not even at equity yet. We’re not even at designing for people yet, let alone with people. I think it’s important to acknowledge when an ideal is in fact an aspiration and to be careful with how and when we say we are designing with versus for.

Improving health outcomes requires a behavior change — but it’s time to challenge whose behavior is on the examination table.