In terms of what the students wrote. Bonus points were a priority. When I started out, I wanted that extra credit. You bet I wanted my grade, but whoa, now I'm really feeling better, and that's what kept it going. I felt a measurable difference. I felt like I was doing something good for myself. So the health benefit that I was achieving as a result, that's what I wanted. This is something we know from behavioral psychology, from health psychology. Intrinsic rewards are much more powerful in initiating and in motivating, and certainly in maintaining behavior change. So the key is to keep the extrinsic rewards going as much as you can until the intrinsic ones take over. So I feel like we really learn something from those early criticisms that said, "The intervention just wasn't long enough." It wasn't, I agree. We need to keep it going for the duration of the semester to see whether or not the intrinsic stuff would sort of takeover, and it seemed that for at least some people it did. I'm curious if this was picked up on or was there a point where there was a drop-off? Where you felt like there was a period of time after which a large number of students started falling away because they didn't make that jump into the intrinsic reward? I don't know because of the extra credit was applied for the duration of the entire semester. Some people even wrote it like it was opportunity costs. I'd been doing it for seven weeks, I didn't want to lose those points on the last two weeks of the semester. So having that kind of all or none. It wasn't actually all or none but the extra credit points were administered on and graded. I mean a graduated continuum so that if people did it for 70 percent of the days, they still got some extra credit points. But those who did it for the duration of the semester, it was like 154 opportunities for behavior over the course of the different domains for those who did it all, and I think I cut it at like 95 percent. They got a full 10 points, which meant a full letter grade added to their grade. So that's a motivator for Yale is, it really is. It really just gives that extra boost of incentive on the couple weeks where you might be struggling to be able to prioritize these things. Yeah. Absolutely. Yeah. Definitely interplays. Right. It was the most powerful reward that I could I think of, and it ended up being one that I didn't need to have a budget for it. Well, it's interesting because it's a reward that works because it's the direct response to the cause of the stress, right? Exactly. When you are stressed about grades and that is the primary excuse not to do the self-care where suddenly you are going to have to do it in order to reduce the stress that kind of is coupled. Yeah. Exactly. But then what was just the more glorious outcome of this is that people then were like, "Yeah, I kind of knew that my grade was in the bag, but now I want to do it for myself because I feel better," and that's the ideal. Yeah, absolutely. I think some of these like adding an extra serving of vegetables or an extra serving of fruit seems really insurmountable at the beginning, but once I know a lot of the habit research has shown, once six weeks have passed, seven weeks have passed and it's a habit, you're like, "Oh, it actually isn't that hard to just remember to eat one more zucchini, per se." So I think being able to incorporate that forward it's definitely seems like this has good potential to continue beyond the class. Yeah. I hope so. This is where I think the qualitative research could be very interesting on how they report at what point they felt that shift happen and how it will continue in the semester moving forward when the grades fall away. We'll see. That's study is in progress actually. Fancy. Okay. Additional lessons learned. Talking about this notion of self-efficacy. If one is afforded through their experience increased confidence in their ability to meet these behavioral goals, how much farther that will go? So some students drew this back to their own professional goals. Many who are hoping to go into medicine and others in public health, but generally, most of these students are focused on wanting to improve health of others. Tying this to if you as a professional believe in your patients, your constituents' abilities, and as a result, your own ability, then everyone is more likely to succeed in these health behavior change goals or programs. Someone else pointed out that we should strive to exhibit for the benefit of not only us but for those around us in both professional and personal settings. This is why I think it's so important that I and all of the teaching fellows in the class also participated in this health behavior change things. Even the experts have areas where we could likely benefit even if they're minor. Life happens to everyone, and so it's really important to focus not only on ourselves, not only so that we can be there for others, but because it's an important empathic exercise to understand where everybody else is coming from. So this person talked about how making a difference in even just one individual can have sort of a ripple effect and potentially branch out even farther. I do know from reading papers and from talking to the students over the past couple of years that a lot of them then recruited their roommates and their suitemates and people who weren't enrolled in the class would jump on and start to engage in these improvement projects overall. I mean, if you've ever experienced that were someone in your suite or your roommate has decided, "Hey, we're going to do something," and "Okay, I guess we are." That's what a culture of wellness starts becoming, right? Yeah. Absolutely. I think definitely within my experience as a student-athlete, if the team or the coach or particular members of the team decide to commit to doing something, you see a ripple effect because you're around these people so often that it becomes more apparent how easy it is to incorporate it and it's almost like this positive form of peer pressure. So I think in my experience that's worked pretty well in a team setting, especially. Awesome. Glad to hear it. I've loved hearing from students in my class too who have children, that they have started to do this and then their kids want to jump onto and they'll go, "What are you doing? I want to do that also." Well, that's just the cutest example you could have. Well, I think it's pretty relevant if we think about our health choices throughout the lifespan and just who we're affecting by them. Yeah. So in conclusion, additional studies are planned. We are going to look at the durability of these outcomes. But this wraps up the course in health behavior change from evidence to action.
