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KRIENS, Switzerland: Stable routines lie at the heart of habits. Lately, however, the COVID-19 pandemic has shown us the challenge of fostering habits in times that are disruptive. Taking the view that periods of change provide opportunities for creating habits that promote better health, a recent study by the Gottlieb Duttweiler Institute explored what support is needed to achieve this. The answer? A prevention-based healthcare system that is nothing like the one we know today.
In a world that is in constant and ever-faster change, creating and maintaining health-promoting habits requires a great deal of self-control and conscious planning. Owing to the direct impact of our habits on our health, teaching these skills is becoming increasingly important in the preventive work of any medical field, oral health included. Let us take a look at what habits are, and how we can use them as tools for long-term health.
The power of habit
Habits, in their most narrow definition, can be defined as behaviours that occur in the same place every day. Humans are creatures of habit: according to American psychologist Prof. Wendy Wood, habits constitute no less than 40% of our daily lives. Widen that definition to behaviours that occur not daily but on a regular basis and that figure rises to half a day.
Most habits are subconscious. According to one study, a behaviour has to be repeated for 66 days on average for it to become such an automated habit. More than not skipping a single day, the decisive factor for internalising a habit was found to be a stable environment triggering the automated behaviour. As such, habits can be understood as reflexive responses to a particular situation.
But here is the problem: if habits are rarely questioned, unhealthy ones can slip in easily. As behaviours related to oral hygiene are habits too, it is crucial to foster only those that are beneficial. But how?
Routine is everything
Our surroundings have a major influence on our behaviour. For this reason, health interventions often tend to focus on environment rather than trying to change habits directly. However, changing a person’s environment in such a way as to encourage a healthy lifestyle requires a certain degree of stability in his or her life. The more stable a person’s life, the more he or she resorts to habits. A person could place a toothbrush on his or her desk at work to remind him or her to brush after lunch, thereby creating an environmentally triggered habit, for instance. In other words, habits are malleable.
When it comes to oral health, changing behaviour is only one side of the coin. Avoiding bad habits and maintaining those behaviours that promote health—even in a changing environment—is the other.
The great disrupter: COVID-19
In today’s society, change is a constant. Climate change and the quickly evolving job market, for instance, require constant flexibility from people. Since last year, most of us have seen our lives disrupted by the COVID-19 pandemic. Whether it be diet, working out or smoking, the impact on our health was obvious. Researchers found that overweight people tended to eat more during the pandemic, whereas underweight people tended to eat even less. Two in five people exercised less; one in five exercised more during lockdown. Regarding the habit of smoking, 2020 saw more young adolescents than ever take up smoking, while more people than ever successfully quit.
It seems that the pandemic led some to further divergence from a healthy norm where others saw a window of opportunity. Clearly, change is not necessarily negative. But what is it that connects those people who manage to turn change into health-promoting habits? The answer may lie in one specific skill: self-regulation.
The importance of self-regulation
If the pandemic has taught us one thing, it is that change often means drifting off into easier behaviour. Still, this does not necessarily have to be the case. When routine takes a hit, it takes conscious action in the form of self-regulation to maintain or establish a healthy habit. In short, self-regulation is the ability to consciously control and reflect on one’s own behaviour and to plan it in the long term, rather than to act on short-term impulses only.
According to Dr Urte Scholz, professor of applied social and health psychology at the University of Zurich in Switzerland, pursuing a healthy lifestyle is not something that people are predestined to do. Several environmental factors can hinder our ability to self-regulate, including financial insecurity, mood or mental health, level of education or income, and social integration. However, governments, employers or communities could provide people with the appropriate tools and environment.
A society in transition
If self-regulation were to be implemented on a societal level, we could expect that greater importance would be attached to prevention than is currently the case. In Switzerland, for example, a meagre 2.6% of total healthcare expenditure was on prevention in 2020. Scandinavian countries, by contrast, are aiming to reach 50% by 2040. A healthcare system that favours preventive care over acute treatment would not only be more effective in the long run, but be cheaper as well.
Today, several developments are already pushing healthcare systems towards prevention. The growing datafication and gamification of health through apps and trackers, for example, are leading to increased health literacy among the population. New insights in medicine have improved our understanding of the interrelatedness of different conditions. Oral disease has been linked to diabetes, cardiovascular disease and premature birth. In ageing Western societies, the focus of healthcare systems is increasingly being shifted towards chronic disease, chronic stress and mental health issues.
A healthier world starts with us
An ideal prevention-based healthcare system would empower its users towards making informed decisions about their health. This motivation could be achieved by teaching children from a young age to see their health as an interaction between physical, psychological and social factors. This would enable them to understand the consequences that their habits hold for their health. If social norms were to be based on such an informed understanding of medical topics, media would most certainly look different. Sharing healthy behaviour on social media would intensify a person’s identification with this part of himself or herself, and it would lead to a healthy sense of community for others. According to Lukas Zahner, head of the Certificate of Advanced Studies (Personal Health Coach) project, health insurance schemes want a quick fix, and customers do too. A healthcare system that sees healthcare as a continuous service rather than a one-time solution would offer its users the tools and infrastructure to consciously take part in their own healthcare, a collective self-regulation towards better health.
Of course, certain capabilities must be enabled to perform health-related habits correctly, such as brushing programmes that teach correct dental hygiene, and governments, employers and communities need to provide the infrastructure to do so, either in the form of financial support, encouraging social interaction, providing a holistic health coach or urban planning where necessary amenities are within walking distance. One potential scenario in the future might be a health coach as a first point of contact for all health-related questions. This health coach would work in a multidisciplinary environment to avoid referring people from one specialist to another. Ideally, these health coaches would also be integrated into the community, in the same building as other public services, which would lower the threshold for access. A digital assistant as a useful tool, rather than taking control over a person’s life, helps with implementing plans, goals and reminders.
An example from Slovakia shows that change on a large scale is possible. In eastern Europe, a staggering number of children visit their dentists only in case of dental emergencies. The number of dentists per capita is low, and a great proportion of them are older than 60. Parents have complained of dentists refusing to treat their children, especially regarding preventive treatment. In 2006, the joint Dental Alarm project between Swiss oral health brand Curaprox and non-governmental organisation Občianske združenie Zdravé ďasná set out to change this through educating Slovakian children at kindergartens and schools. Children are taught about the importance of oral health, receive motivational tools and brushes, and their parents are involved in their brushing routines. The consequences are enormous: since the project was started, the number of dentists per capita has been steadily increasing, and a new generation of prevention-minded dentists are turning the country into an example of preventive oral healthcare. There are 650 Dental Alarm trainers, and 110,000 children have taken part in the programme.
As this example shows, this future prevention scenario is not an impossible one. The hurdles are not technical or financial, but social. We need a mentality change, away from the reductionist approach and towards a more preventive, interdisciplinary and holistic approach. In such a healthcare system, we would no longer talk about “patients”, but “users”. We would no longer see health as a series of acute interventions but as a lifelong project.
Editorial note: The Prevention in Transition study is a collaboration between Swiss think tank the Gottlieb Duttweiler Institute and Swiss brand Curaprox. Under the motto “Better health for you”, Curaprox offers holistic, prevention-oriented oral health services and products. The study can be accessed here.