Cheating ourselves to Death?

India is often referred to as the diabetes capital of the world, with around 41 million people living with diabetes in 2007, and projected to reach 68 million by 2025. In one of our engagements we were trying to understand how people living with diabetes manage this disease. One of the perplexing observations was that many people had the belief that their diabetes is under control. This conflicts with most data and expert opinion which suggests that majority of diabetes cases are uncontrolled.

We were trying to understand the source of this belief and started interviewing close family members of patients. One of the most interesting factors that we heard when we spoke to family members of these patients was that these patients “prepared” themselves before going for a blood glucose test. A week before they get their blood sugar tested, they would change their lifestyle – they would exercise, go for walks and control their diet. So when testing happens they get a more favorable result than their actual condition. It looks so irrational that people would cheat themselves into believing that their condition is better than it actually is, thereby putting themselves at risk of not getting the right treatment.

What explains this seemingly irrational behavior? Why would intelligent people who are aware of the dangers of the disease that they have, not want to know the truth and provide their physician with more accurate data for better decision making?

One of the moderators of decision making is the kind of mental models that people create in life that helps them simplify the world. While this is often great to improve efficiency of decision making, it could be deadly if used in the wrong context. A very popular example of a mental model being used in the wrong context is in the case of diarrhea. As Sendhil Mullainathan explains in this video, 35-50% of the mothers in Rural India think that they should reduce fluids if their child has diarrhea. They use an intuitive mental model of a leaky bucket – that you should not pour water into a leaky bucket if it has to stop leaking. This makes diarrhea, something that can be easily managed to the status of a deadly condition.

In the case of diabetes, the mental model that patients have is that one should not to fail a test. People look at each blood test as a test of how well they are managing their condition, thereby framing the issue as a judgment on their own capabilities. And not one that objectively measures the status of their condition and as an input into a treatment regimen that would help their doctor take better decisions.

How do we address such a condition? Breaking mental models is often a high-investment long-term game. One of the approaches that we take at Final Mile is to see how one can work with existing mental models rather than fight it. In this case, simply by encouraging people to adopt HbA1C instead of a spot test can help address this behavioral issue and get a more accurate measure of their condition. It is a simple intervention, but one that addresses the inherent risks of misdiagnosis. The other intervention is to address how doctors and counselors frame the test – it is important that patients do not see this as a test that they fail or pass but one that helps calibrate the medication for a chronic condition.

One thought on “Cheating ourselves to Death?”

  1. We all behave according to what is measured. So, for a diabetic, if spot tests are the key, it is a normal and rational response to pep up the results by last week changes. HbA1C is a good option. Another option would be to create process measures – doctors could create a check sheet for daily walks, food eaten, etc and ask the family members to update it daily. Maybe this could be a phone app that is accessed by the family member of the patient (and not the patient). The idea is to shift from measuring outcomes to measuring processes.

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