Unhealthy behaviors are responsible for a high percentage of health care costs and poor health outcomes. In large companies, unhealthy behaviors by employees are considered an important challenge to affordable benefits coverage. Employers increasingly leverage incentives to encourage changes in employees’ health-related behaviors. In this viewpoint, the authors discuss the potential and the limitations of commitment devices, as distinct from incentives, to influence health behaviors.
Many people intend to improve their health behaviors in the future, but when the future arrives, they fail to follow through. Many will precommit their “future selves” to follow-through by purchasing gym memberships or scheduling workouts with friends; persons with alcoholism take disulfiram in the morning so drinking alcohol in the evening will make them ill. The commitment devices increase the probability of individuals’ compliance with voluntarily imposed restrictions until they have accomplished their goals or their voluntarily imposed penalties for not reaching their goals.
A common form of commitment device, also called a deposit or commitment contract, involves people voluntarily depositing money into accounts they can access again only if they accomplish a goal. These devices can help people lose weight, improve their diets, exercise more, and quit smoking. Such commitment devices have 2 basic features: people voluntarily use them and the devices link consequences to an individual’s failure to achieve preset goals.
Commitment devices can be associated with various consequences. Immutable consequences cannot be reversed by future choices. They can have monetary aspects in which people risk losing their own money if, by a predetermined date, an independent assessor reports that they did not reach their goals. Commitment devices involving mutable consequences constrain future behaviors but allow people future latitude to mitigate the consequences. One form is temptation bundling or allowing people to restrict their access to instantly gratifying experiences only to occasions in which they engage in goal-consistent behaviors.
Commitment devices are powerful tools for changing health behaviors, but they are underused. Maximizing the population health benefits of commitment devices requires increasing the numbers of people who use them and increasing their effectiveness. Health professionals can educate patients about the gap between intention and action. Making enrollment and participation as simple as possible by eliminating unnecessary complexity could also facilitate greater use of commitment devices. To improve population health, such devices need to be more effective. Often, health-relevant goals require changing long-term behavior even after an initial objective has been achieved. Research should investigate whether and how commitment devices can be effective tools to assist with long-term behavior change. Commitment devices can provide positive feedback as soon as people begin using them. One promising direction for future research involves leveraging the influence of existing social networks. Commitment devices that involve these networks by creating social consequences for failing to achieve goals can be implemented inexpensively.
Patients are more successful at achieving their health goals when they have access to commitment devices. Strategies for achieving higher rates of ongoing engagement and sustained behavior change are needed for the devices to have widespread influence and benefit.