Enjoyment usually outperforms self-efficacy as a predictor of success.

Enjoyment also predicts follow-through better than perceived importance.

For health programs, adherence isn't always an the active ingredient, but it should be.

Design health interventions to ensure participant repeatability, then let outcomes follow from repetition.

For my colleagues and me, whose task it is to improve population health, we architect specific health interventions because doing so gives us a measurement advantage. Through good intervention design, we (or the intervention's facilitators) can track attendance, program completion, vital signs, functional capacity, clinical labs, and downstream health utilization. Yet, despite our best design efforts, we still chronically face a fundamental challenge: program adherence.

When intervention attrition inevitably occurs, we often blame the population pool. I mean, discipline is hard, right? So, as behavioral scientists, we play with the variables. We lower the stakes. Maybe we try new nudges, like increasing the reminders, manufacturing accountability, and/or adding more education to amplify the clinical case. But, in my opinion, for too long we've been missing the simplest variable: what the pursuit feels like to the person we hope to engage.

Since I wrote The Fun Habit, there's been growing evidence-based support for my assertion that people tend to stick with what they enjoy more consistently when compared to other variables. Simply put, we follow through when the process is psychologically rewarding, not merely when the outcome is logically important.

Even though this phenomenon is well understood academically, I find it's still met with resistance time and time again in medical and/or health settings. To some, it sounds like a whimsical assertion that we need to "entertain" patients and clients. Other times, the resistance is in the form of aversion to treating disease management like a leisure product. Unpacking this resistance is out of scope for this article and will be addressed in a future article. For now, let's focus on the fact that, despite this aversion, the evidence supports a precise point: enjoying what you're doing is paramount to adherence. Fun (deriving pleasure from an activity) is our nervous system's real-time valuation of whether a behavior is worth repeating.

Why "importance" fails at the moment of choice

Research led by Dr. Kaitlin Woolley and her colleagues helps name the problem. Across multiple experiments, their research has found that people pursue goals longer when they find the pursuit enjoyable and personally rewarding. Perceived importance matters less than most of us assume. In their study, the effect held across goal domains and cultures and was evident in both self-report adherence and behavioral measures such as step tracking.

Why is this true? Perceived importance is a cognitive judgment. It often lives in the part of our mind that makes plans, sets intentions, and argues for the right thing. The moment of choice runs through a different system. When our energy is low, when our stress is high, when pain is present, the brain doesn't consult a values statement. It consults predicted experience.

What I've witnessed in my two decades of health management and medical fitness is that our predicted experience is generally shaped by our most recent experiences with a particular activity. We consider internal questions, like:

Did it feel punishing?

Did it feel like competence?

Did it feel like belonging?

When the predicted experience is viewed negatively, importance then has to do all the work. That's a fragile arrangement for any long-term intervention!

Enjoyment can outperform confidence

Medical fitness has often leaned heavily on self-efficacy. We design programs under the guise that the participant's belief that they can perform the behavior should be our primary behavioral target. That makes sense, sort of. Confidence predicts initiation and persistence in many contexts, and it's one of the most practical constructs for coaching and program design. Yet the exercise behavior literature has been quietly updating this hierarchy, and I feel it's my duty to start shouting it now: Enjoyment > Confidence!

For instance, a controlled trial published in Psychology & Health compared self-efficacy and perceived enjoyment as predictors of physical activity over time. Their sample included hundreds of adults who were low active at baseline. Participants received either a print-based physical activity promotion program grounded in established behavior change theory or a comparison program. Over the follow-up period, both self-efficacy and enjoyment predicted later physical activity.

What emerged from the research? When enjoyment and self-efficacy were entered together, enjoyment held; self-efficacy did not. Follow-through tracked more closely with how much people enjoyed being active than with how confident they felt about being active.

What does that mean? Enjoyment didn't merely sit beside self-efficacy as an alternate predictor. It appeared to feed self-efficacy. As enjoyment improved, self-efficacy improved, and that pathway helped explain later activity.

Why is that important? That's a different causal story than most health programs assume. It suggests practical reordering of design priorities: Improve the felt experience of the pursuit, and confidence often follows.

This aligns with related work in clinical populations. In a study of cancer patients participating in structured programs, enjoyment increased during the intervention and directly predicted physical activity level immediately after the program, adding explanatory value beyond self-efficacy in regression models. Taken together, these findings support a shift that matters for medical fitness operators and healthcare partners. Self-efficacy is worth cultivating, yet enjoyment is not a soft add-on. It can be a primary driver and is likely upstream of confidence.

Adherence is the intervention

In acute care, interventions can be delivered to a passive body. In lifestyle medicine and medical fitness, the intervention is a behavior sustained over time. That fundamentally changes what "effective" means. A program is not effective when it's well-designed on paper. A program is effective when people keep doing it long enough for the minimal viable dose to accumulate.

This is why adherence deserves to be treated as a primary outcome rather than a secondary nuisance variable. (In fact, pruning dropouts is one cause for a lot of critical takes on wellness research, given its propensity for creating selection bias.) Adherence shouldn't be something that's considered as happening during (or after) the intervention. In many cases, adherence actually should be considered the intervention! Seen through this lens, enjoyment is no longer a luxury. It should be the predictive variable we focus on as an intervention designer. If the pursuit of an intervention is experienced as punishing, tedious, or socially uncomfortable, the program is essentially prescribing dropout risk.

Pursuit-first design in medical fitness

The good news is that designing for fun doesn't require gimmicks. Here are a few design considerations I've pulled directly from the science of enjoyment and adherence, which translate cleanly into operator practice and healthcare partnerships.

1) Treat affect as data, not as mood

Affective response is often more informative than motivational talk. Programs can track it with simple tools. For instance, a brief enjoyment rating after sessions, a question about desire to return, and/or a short check-in on what felt good or bad. These measures should be treated as important leading indicators. For instance, if early affective signal trends negatively, expect adherence problems even when people endorse high importance.

2) Preserve autonomy inside guardrails

Referral-based programs carry constraints, contraindications, intensities, movement restrictions, and monitoring protocols. Autonomy still exists inside those constraints. Offer modality choice, pacing choice, music choice, time-of-day choice, sequencing choice, and social choice. Give people a sense of authorship. When the person experiences the program as something done with them, not to them, the pursuit gains psychological ownership.

3) Engineer competence experiences early and often

Self-efficacy is built through mastery. Mastery does not require maximal effort. It requires repeated experiences of success. Design sessions so the default experience is, "I can do this, and I can feel myself improving." Make the win visible within the session, not only in distal outcomes. Competence without shame is a retention tool.

4) Use belonging as a clinical lever

Many medical fitness participants arrive with identity threat. They may feel behind, judged, or out of place in fitness environments. Belonging is not a marketing concept here; it's a design consideration for better adherence. Small cohorts, stable coach relationships, and peer norms that celebrate consistency over intensity can shift predicted experience. When people feel safe and accepted, the pursuit becomes easier to repeat.

What this change looks like for operators and healthcare partners

If you accept that adherence is interconnected to any given intervention, program design priorities shift.

You still track outcomes. You just stop treating outcomes as the primary consideration.

You still value education. You just stop assuming education produces repetition.

You still coach confidence. You just start paying equal attention to enjoyment as a precursor.

Referral pathways often assume motivation resides inside the patient or client. A pursuit-first lens treats adherence as a shared design problem. The program's job is to create an experience that people want to return to and that clinicians trust. When we can get this right in designing health interventions, better outcomes are almost guaranteed to follow. They become the natural consequence of a pursuit that's sustainable.

Ekkekakis, P., & Brand, R. (2019). Affective responses to and automatic affective valuations of physical activity, fifty years of progress on the seminal question in exercise psychology. Psychology of Sport and Exercise, 42, 130–137. doi:10.1016/j.psychsport.2018.12.018

Lewis, B. A., Williams, D. M., Frayeh, A. L., & Marcus, B. H. (2016). Self-efficacy versus perceived enjoyment as predictors of physical activity behaviour. Psychology & Health, 31(4), 456–469. doi:10.1080/08870446.2015.1111372

Magnus-Sharpe, S. (2025, July 16). The secret to resolutions? Enjoy the pursuit, not the outcome. Cornell Chronicle.

Rhodes, R. E., Fiala, B., & Conner, M. (2009). A review and meta-analysis of affective judgments and physical activity in adult populations. Annals of Behavioral Medicine, 38(3), 180–204. doi:10.1007/s12160-009-9147-y

Ungar, N., Wiskemann, J., & Sieverding, M. (2016). Physical activity enjoyment and self-efficacy as predictors of cancer patients’ physical activity level. Frontiers in Psychology, 7, 898. doi:10.3389/fpsyg.2016.00898

Williams, D. M. (2008). Exercise, affect, and adherence, an integrated model and a case for self-paced exercise. Journal of Sport & Exercise Psychology, 30(5), 471–496. doi:10.1123/jsep.30.5.471

Woolley, K., Giurge, L. M., & Fishbach, A. (2025). Adherence to personal resolutions across time, culture, and goal domains. Psychological Science, 36(8), 607–621. doi:10.1177/09567976251350960

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