Lecture 9
Real-World Implementation and Behavioral Change: Designing Care Pathways, Continuity of Care, and Patient Navigation

(1) Introduction to the lecture

Norie KAWAHARA opened the ninth lecture of the Spring 2026 semester of the Surviving Cancer in Asia: Cross-boundary Cancer Studies lecture series by introducing the week’s theme, Real-World Implementation and Behavioral Change: Designing Care Pathways, Continuity of Care, and Patient Navigation, framing its aim as showing prevention not merely as policy but as something lived out in a patient’s body, day by day.

The session was placed within the arc of the series as a whole. Prevention had been redefined across the semester as more than individual behavior or a means of reducing future healthcare costs, becoming instead a social foundation supporting Universal Health Coverage, healthy aging, and a more sustainable society. Building on Dr. Takemi’s vision of a “Creative Future” and the bridge already built toward implementation research in Malaysia, Dr. Kawahara noted that this lecture would set out to construct one further bridge, connecting large-scale policy and institutions to the daily life, body, and recovery process of a single patient. Five terms anchored the discussion: real-world, behavioral change, care pathways, continuity of care, and patient navigation. Good medical technology and sound philosophy alone were described as insufficient; what mattered is whether a patient could continue treatment in daily life, move their body, overcome anxiety, pain, and fatigue, and who would support them, when, and how.

Scale came next, with GLOBOCAN 2022 figures cited showing that Asia accounts for roughly half of new cancer cases worldwide and more than half of global cancer deaths, with case numbers projected to rise sharply toward 2050 — an immediate concern rather than a distant one. Beyond primary prevention and early detection, attention needed to expand to consider how patients maintain their bodies, continue treatment, and return to daily life after diagnosis, surgery, and chemotherapy; this next frontier was framed as encompassing secondary prevention, recurrence prevention, and wellbeing in cancer care across the region.

Dr. Kawahara then introduced the two speakers. Dr. Nobuhisa Matsuhashi of Gifu University, working at the clinical frontline of gastrointestinal and pediatric surgery, would offer a practical perspective on care pathways, treatment continuation, and postoperative recovery. Dr. Kazushige Sasaki of the University of Tokyo’s Graduate School of Arts and Sciences would approach the same question through the body, exercise, and life sciences, examining how patients could be supported in believing they were able to move — framed as a matter less of muscle training than of rebuilding trust in one’s own body and sustaining behavioral change.

Several studies that are currently in planning or already underway were cited to illustrate what this looks like in practice. One study in planning prospectively examines the effect of low-load, standardized slow training during chemotherapy on continuation rates, skeletal muscle mass, and quality of life in patients with recurrent or metastatic gastrointestinal and breast cancer, with a related approach using the Hybrid Assistive Limb (HAL) robotic exoskeleton for post-chemotherapy squat training; and another evaluating HAL-assisted early postoperative physical therapy after gastrointestinal cancer surgery, assessing mobilization, physical function, muscle mass, complications, length of hospital stay, quality of life, and the resulting workload for nurses and physical therapists. 

HAL, previously introduced in Lecture Three by Dr. Yasunaga, was reframed away from technological novelty. Dr. Kawahara noted that its significance lies in connecting a patient’s will — the intention to stand, walk, or move — safely to actual bodily movement. This extended the meaning of patient navigation beyond the path to a screening appointment, to include the support that helps a patient take their next steps during treatment, after surgery, and in returning to life. In this way, exercise, slow training, and HAL were positioned as part of a care pathway carrying a patient’s life into its next stage.

While noting that research is still unfinished and in the process of development, Dr. Kawahara explained that foundational work is being done in Japan before joint research begins with Malaysia, and the lecture series itself was credited with having, in some measure, helped spark that research. 

Dr. Kawahara noted that the lecture today should be understood in the context of applied research rather than medicine or exercise science alone. She raised potential questions such as scenarios in which treatment continuation becomes difficult, who sustains behavioral change and how, what must be measured to demonstrate prevention’s value to society, and how the model might extend to cancer care in Malaysia and across Asia. 

Even as artificial intelligence advances, moving the human body was described as a challenge that persists to the end — not simply exercise, but the strength to continue treatment, return to life, and support recurrence prevention. 

(2) Cancer Prevention and Physical Activity

Nobuhisa MATSUHASHI noted that the prime modalities in conventional treatment for cancer remain anti-cancer drugs, surgery and radiotherapy either utilized solo or in conjunction with each other, on a case-to-case basis. In cancer treatment, as well as prevention, the role of traditional and complimentary medicine along with physical activity is gaining traction worldwide. Physical activity is an essential lifestyle measure for maintaining optimum health.

  The World Health Organization (WHO) has defined physical activity as any bodily movement produced by muscles requiring energy expenditure. WHO recommends adults to do at least 150-300 minutes of moderate-intensity aerobic activity, or an equivalent mix of moderate and vigorous intensity activity throughout the week.

Regular exercise if incorporated in daily routine can provide the necessary boost to immunity, maintain optimum weight and regulate the hormonal balance in the body.

  In terms of hormonal balance, raised levels of these hormones increase the risk of breast cancer. A study from United Kingdom demonstrated that the risk of breast cancer reduced significantly by 9% (P < 0.001) with physical activity. A meta-analysis of prospective cohort studies demonstrated raised levels of these hormones are associated with increased risk of endometrial cancer. Studies have revealed significant reduction in prostate cancer risk associated with vigorous physical activity.

  In terms of obesity, adipose tissue releases adipokines that regulate energy homeostasis and inflammation. Elevated leptin and visfatin levels, coupled with low adiponectin, are implicated in carcinogenesis. For instance, in case of colorectal cancer, leptin induces the growth of neoplastic colorectal cancer cells. Ahechu et al reported chronic inflammation is another mechanism of cancer development. In case of reproductive organs, leptin stimulates endometrial, breast, and ovarian cancer cell growth and impairs apoptosis through activation of multiple signaling pathways. In addition, it induces hyperestrogenism via increasing the expression of aromatase.

  It has been demonstrated that regular physical exercise reduces insulin resistance. It has also been noted that insulin resistance leads to hyperglycemia and hyperinsulinemia further associated with an increased risk of neoplasia, poorer prognosis and greater risk of relapse after initial treatment. Insulin resistance may lead to altered metabolic (MET) states leading to obesity and type 2 diabetes.

  Exercising in open air has the benefit of increasing vitamin D levels via increased sunlight exposure. Vitamin D has a role in the modulation of cell differentiation, proliferation, and apoptosis of neoplastic cells, as well as the antineoplastic action of the immune system. The beneficial effects of physical activity in the sun in preventing cancer are indirect. There may be via beneficial effects of sunlight on the immune system and circadian rhythm. 

  In terms of immunity, tumor cells evade immune destruction through mechanisms such as elevated lactate levels, impairing cytotoxic T-cell function. This mechanism promotes tumor growth. They accomplish this task via various methods. elevation of lactate levels within cancer cells is one such method. This affects the functioning of cytotoxic T cells thus escaping elimination. Muscles secrete muscle cytokines or myokines on physical activity. These mediate beneficial functions on the immune system. Subsequent to dynamic exercise (rowing, cycling, swimming), there is an acute mobilization of leucocytes to the blood compartment.

  There is strong evidence that physical activity can reduce cancer incidence, the strongest evidence being for breast, bladder and colorectal cancer. A large-scale study conducted in the United Kingdom using data from the UK Biobank investigated the relationship between how much people move in their daily lives and their risk of developing cancer. Physical activity was objectively measured using accelerometers, and participants were categorized into five groups (quintiles) ranging from the lowest to the highest levels of total physical activity for comparison. This study evaluated a composite outcome comprising 13 cancer types considered to be closely related to physical activity, including cancers of the esophagus, liver, lung, kidney, stomach, uterus, hematological malignancies, colon, head and neck, rectum, bladder, and breast.

The analyses statistically examined the association between physical activity and cancer risk while accounting for a wide range of potential confounding factors, including age, sex, smoking status, alcohol consumption, dietary habits, socioeconomic background, and overall health status. For women, additional adjustments were made for hormone therapy use and reproductive history.

The results showed that individuals with higher levels of daily physical activity tended to have a lower risk of developing these cancers. This inverse association was observed in both men and women and was supported by the study’s large sample size and long-term follow-up.

  There has also been a Japan Collaborative Cohort Study into physical activity and bladder cancer risk. This study has shown that cancer risk is greatly reduced when people’s work includes a majority of standing and walking. The more physical activity a person engages in then the more the cancer risk decreases (up to 60%). The preventive effect is particularly strong in men. 

  The association between physical activity after a colorectal cancer diagnosis and survival was studied in the CALGB 89803 trial. CALGB 89803 was a phase III trial comparing adjuvant IFL with 5-FU/LV in stage III colon cancer, which did not show superiority of IFL.  Patients with a physical activity level of ≥18 MET-hours (See Figure 1 for explanation of MET) per week (e.g., ≥6 hours of brisk walking per week) showed a marked reduction in the risk of recurrence and death. When comparing the most active group (Q4) with the least active group (Q1): Disease-free survival (DFS): HR 0.51 (49% risk reduction) Overall survival (OS): HR 0.44. The level of physical activity remained a significant independent prognostic factor, regardless of chemotherapy regimen, body mass index, or tumor characteristics. (Figure 2) 

In 2025, a significant study was announced in The New England Journal of Medicine. (Courneya, et. al, “Structured Exercise After Adjuvant Chemotherapy for Colon Cancer). This study involved patients with high-risk Stage II or Stage III colorectal cancer who have completed postoperative adjuvant therapy within 2 to 6 months after curative resection (Figure 3). 

In terms of disease-free survival (DFS) one in every 16 participants avoided a cancer recurrence or a new cancer as a result of exercise. In terms of overall survival, the improvement in OS is driven by a reduction in colon cancer-related mortality. Exercise interventions helped to prevent one death for every 14 participants. 

  A further study titled Exercise-nutrition prehabilitation attenuates lean body mass before gastrectomy: a randomized controlled trial (Yamamoto et al), showed only a modest benefit of exercise. However, this adherence analysis tells us something very important. Patients who completed both resistance training and HMB supplementation preserved lean body mass significantly better than controls, whereas poor adherence resulted in almost no benefit. Therefore, the effectiveness of prehabilitation depends not only on the intervention itself but also on patient adherence. 

  In summary, exercise does not work unless patients actually do it. The key is not only prescribing exercise, but also helping patients sustain it.

(3) ESMO Clinical Practice Guidelines for diagnosis and treatment

Systematic reviews and meta-analyses focusing on the role of physical exercise in patients with cancer during active treatment have documented an improvement in domains such as cancer-related fatigue (CRF), physical and muscular strength, activity levels and aerobic fitness.

There is growing evidence that physical exercise can attenuate systemic inflammation and improve CRF, allowing patients with or without cachexia to become more capable of carrying out the activities of daily living (ADLs) and thereby to improve the functional quality of life (QoL).

Despite significant evidence for exercise in the management of CRF, an exact exercise prescription for patients with CRF does not exist. Current exercise prescription guidelines focus broadly on the general well-being of patients with cancer, encouraging 150 min/week of aerobic exercise, 2 days/week of strength training and flexibility exercises on days when aerobic or resistance exercise is not carried out. Some observational and interventional studies have also suggested that patients with cancer who engage in at least 3-5 hours of moderate activity weekly may experience better outcomes and have fewer side-effects of anti-cancer therapy, including CRF.

Based on the results of randomized controlled trials (RCTs) and systematic reviews, physical exercise can be recommended in non-cachectic patients with cancer. Physical exercise of moderate intensity and aerobic and functional resistance exercise are recommended in patients with CRF. Physical activities like walking and home-based aerobic and resistance exercises are recommended to improve CRF and QoL.

  Aerobic exercise (walking, etc.) is exercise that helps to prevent cancer recurrence, whereas resistance exercise (strength training) is exercise that builds a body capable of completing cancer treatment. 

  Cancer survivors consider cancer-related fatigue to be the most distressing symptom of cancer and its treatment. Even more distressing than pain, nausea, or vomiting. After treatment, cancer-related fatigue is the reason many people are slow to return to work. Exercise is therefore a part of comprehensive cancer care, and not an optional extra. 

  National Comprehensive Cancer Network (NCCN) Guidelines include the provision of cognitive behavioral therapy (CBT) and yoga. CBT is used to break the vicious cycle of negative thoughts, which results in reduced activity, physical decline and worse outcomes. Yoga involves exercise, meditation (focusing thoughts), and control of breathing and emotions. These practices are thought to help balance the body and mind. Yoga has been found to reduce fatigue, improve sleep quality, and lessen anxiety and depression in people with cancer. There is good evidence that yoga reduces fatigue, especially when practiced on a regular basis. Yoga is recommended for the treatment of cancer-related fatigue during and after cancer treatment.

(4) Why exercise matters in GI cancer surgery

In terms of why exercise matters in GI cancer surgery, a multicenter prospective observational study of standardized exercise therapy (slow training) during chemotherapy for patients with GI and breast cancer was implemented to investigate whether participation in a standardized exercise program (Slow Training) improves the completion rate of chemotherapy in patients with gastrointestinal and breast cancers. 

This study matters because exercise is becoming an essential component of cancer treatment, not merely supportive care. Regular physical activity reduces the risk of cancer recurrence, particularly after curative treatment.  During chemotherapy, exercise helps preserve skeletal muscle mass, maintain physical function, and improve quality of life (QOL).Even in patients with recurrent or metastatic disease, appropriate exercise may reduce cancer-related fatigue, improve psychological well-being, and maintain independence. These benefits may enhance treatment adherence and are expected to contribute to improved long-term outcomes and survival.

Exercise should therefore be considered an integral part of comprehensive cancer care throughout the entire disease trajectory. Even after recurrence, appropriate exercise can improve physical function, psychological well-being, and treatment tolerance, which may contribute to better clinical outcomes and potentially improved survival. In short, exercise is medicine in cancer care (Figure 4) and should be viewed as an essential component of cancer treatment.

(5) Discussion

Dr. Kawahara noted that the Asia Cancer Forum is currently beginning a new and potentially groundbreaking study that aims to prevent cancer recurrence through structured exercise. She asked what kind of evidence would be needed for such an approach to become part of standard cancer care?

Dr. Matsuhashi noted that exercise has been shown to help to improve disease-free survival in colon cancers in a joint study by the University of Tokyo and Gifu University. In the future it will be important to conduct further trials to assess the effectiveness of exercise as an essential part of cancer care. 

Dr. Kawahara asked how, in real-world clinical settings, the importance of exercise for cancer patients is understood by physicians, nurses, rehabilitation professionals, and patients themselves?

Dr. Matsuhashi noted that compared with several years ago there have been improvements in the use of exercise in cancer care in Japan. However, challenges remain, as still only a limited number of institutions have established clear strategies for exercise regimens in the course of cancer treatment and care. 

(6) From Physical Activity to Resistance Exercise: Practical Approaches for Everyday Life

Kazushige SASAKI noted that as Dr. Matsuhashi had mentioned in his talk, exercise can be broadly classified into endurance exercise and resistance exercise. As shown here, these two types have contrasting characteristics, and their effects are therefore complementary.

The complementary effects of endurance and resistance exercise can be explained physiologically from the perspective of muscle fiber types. Broadly speaking, our muscles are composed of two main types of muscle fibers, or muscle cells: slow-twitch fibers and fast-twitch fibers. (Figure 5)

Slow-twitch fibers are relatively slow but highly fatigue-resistant, whereas fast-twitch fibers are capable of producing force quickly but fatigue more easily. These two fiber types therefore have contrasting characteristics. Everyone’s muscles contain both slow- and fast-twitch fibers, but the proportion varies from person to person. On average, however, the muscles of the legs consist of roughly equal proportions of the two fiber types. When we move our bodies, we do not recruit these two types of muscle fibers equally at all times. During light physical activities in daily life, mainly slow-twitch fibers are used. Fast-twitch fibers are recruited only during much higher-intensity movements, such as running or jumping.

Therefore, endurance exercise, which is characterized by relatively low intensity, primarily trains slow-twitch muscle fibers. In contrast, high-intensity resistance exercise recruits both slow- and fast-twitch fibers; however, because the duration of each bout is relatively short, the stimulus to the highly fatigue-resistant slow-twitch fibers is limited. Fast-twitch fibers are fatigable and not used extensively in daily life, so even brief periods of recruitment can provide a sufficient stimulus for growth. For this reason, resistance exercise can be considered a type of training that primarily targets fast-twitch fibers.

The table below shows the physical activity and exercise guidelines for health promotion issued by Japan’s Ministry of Health, Labour and Welfare in 2023 (Figure 6). 

Physical activity is a broader concept than exercise and includes activities such as walking for commuting and household activities. In the previous version of the guidelines, which was released more than a decade ago, recommended targets for intensity and duration were presented mainly from the perspective of energy expenditure through physical activity and exercise. In contrast, the new guidelines explicitly include the recommendation of “resistance exercise training on two to three days per week.” In other words, the idea that both increasing energy expenditure through movement and improving muscle mass and strength are important has finally begun to be reflected in Japan’s public health policy.

Taking a look at the data to see how much we walk on average, Japan’s Ministry of Health, Labour and Welfare calculates that people in their twenties to fifties generally take between about 6,000 to 8,000 steps per day. As mentioned by Dr. Matsuhashi, a metric called METs (metabolic equivalents) was developed to estimate energy expenditure during various types of physical activity. METs is short for metabolic equivalence, and it expresses how many times faster energy is expended compared with resting metabolic state, which is defined as one METs.

For example, working at a usual pace is typically classified as three METs. Another important feature of METs is that energy expenditure can be easily estimated by multiplying METs by body weight in kg, and the duration of the activity in hours.

For example, if a person waning 60kg walks at a speed of four kilometers per hour, the estimated energy expenditure would be three METs times one hour times 60 kilograms, which equals 180 kilocalories. When we compare METs barriers across different activities, we can see that walking, household activities, cycling and climbing stair have METs values that are not very different from those of sports such as tennis or basketball.

Therefore, increasing opportunities and time in these types of daily physical activity reliably leads to higher energy expenditure. As is clear from the equation used to estimate energy expenditure, what matters most is increasing the total amount of active time. Whether the activity is continuous or intermittent is basically irrelevant.

Even short bouts of exercise burn fat. During exercise, it may indeed appear that very little fat is being burned, as long as energy is expanded through exercise or physical activity, the body maintains balance. When carbohydrates are abundant, they are preferentially used. And as carbohydrate availability decreases, fat becomes the primary fuel. Therefore, for the purpose of weight loss or fat loss, whether carbohydrate or fat are being used during exercise or physical activity is not a major concern.

In fact, there is a well-known study reporting that lean individuals spend less time sitting. Lean individuals spend less time sitting, whereas in contrast, obese individuals spend less time standing and moving. Everyday activities such as standing and moving throughout the day are referred to NEAT, or “non-exercise activity thermogenesis” and the authors of the study emphasize the importance of this type of physical activity.

There is a tendency to think that people with obesity are less physically active simply because moving is more hard or difficult for them. However, this study has an important follow up. Individuals with obesity were a low in a weight loss program. Although they successfully lost weight, their level of physical activity did not change at all, before and after weight loss.

Conversely, lean individuals participated in a weight gain program, but again, their physical activity levels did not change. These findings suggest that how much a person moves in daily life is largely determined by inherent individual traits rather than being a consequence of body weight itself.

This begs the question: how can we increase our level of daily physical activity? One approach whose effectiveness has been clearly demonstrated is self-monitoring one’s own activity. A meta-analysis integrated findings from multiple studies. When daily step counts were fed back to participants, the number of steps increased by an average of about 2,000 steps per day compared with conditions in which no feedback is provided (Figure 7).

The Nakanojo Study similarly demonstrated that increasing step counts not only raises energy expenditure, but also leads to a wide range of health benefits. Nakanojo is a town located in Gumma Prefecture, where longitudinal data on community residents have been corrected since the late 1990s.

In this study, some participants were provided with activity monitors to measure their physical activity while others were not. The researchers then compared subsequent medical expenditures between those who received activity monitors and those who did not.

In analysis, focusing on community residents aged 40 to 60 years, it was found that medical expenditures among those who are provided with activity monitors decreased by more than 40% between 2009 and 2011. In contrast, no such reduction was observed among residents whose physical activity was not monitored.

In terms of resistance exercise, in recent years, the relationship between the weekly duration of resistance exercise and the risk of mortality and various diseases has become clearer. According to these findings,  with the exception of diabetes, resistance exercise reduces the risks of mortality and many diseases, including cardiovascular disease and cancer. Data shows that for individuals who train three times per week, each session needs to be no longer than about 20 minutes.

Even in classic studies conducted in the 1950s and 1960s, resistance exercise was shown to be highly time efficient.

In addition, our own research has shown that resistance exercise is flexible with respect to training frequency.

If we are talking about performing very short bouts of exercise at a high frequency, many of us would probably prefer to do them at home rather than going to a gym each time. Recent research has shown that for beginners without an established exercise habit, simply using one’s own body weight is enough to increase muscle mass and strength. In addition, training intensity can be further increased with a bit of creativity.

Another recommendation for improving adherence is to integrate short parts of resistance exercise into your daily routine. If exercise can be incorporated naturally into everyday habits, it becomes much easier to perform consistently and to maintain over time. 

Finally, while walking by itself does not substantially increase muscle mass or strength, it does improve insulin sensitivity, which is closely related to the anabolic effect that promotes muscle growth or muscle hypertrophy. Therefore, in older adults who often exhibit reduced insulin sensitivity, synergistic effect of walking and resistance exercise can be expected.

(7) Assignment

Students were asked to record one ordinary day’s step count and main physical activities, calculate MET-hours for that day, and extrapolate a weekly estimate to compare against the course benchmark of 10–20 MET-hours per week (resistance exercise excluded from this calculation). 

Alongside the numerical results, students were asked to submit a one-page reflective report addressing what the self-monitoring revealed about their own behavior and barriers to activity, then extend that reflection to the barriers cancer patients face in sustaining activity during treatment and recovery, and the implications for patient navigation, recurrence prevention, and well-being in Asia. (See Appendix for full text of Student Assignment) 

(8) Discussion

Dr. Kawahara noted that many of the points raised today are very useful not only for cancer patients, but also for students in their own daily lives. She also noted that the Asia Cancer Forum is working together with Professor Sasaki on a collaborative research project focusing on exercise programs for the prevention of cancer recurrence.

She asked Prof. Sasaki to share his thoughts on what are the most important factors that help patients continue exercising over the long term.

Dr. Sasaki responded that in his opinion the biggest mistake is assuming that motivation comes first. In reality, motivation often comes after people start exercise and experience some benefits from it. Therefore, Dr. Sasaki usually emphasizes the importance of making exercise as simply and achievable as possible that will encourage people to continue exercising. Integrating exercise into existing daily routines is a very important strategy and self-monitoring is also very powerful, whether that be tracking daily steps, or minutes spent exercising, etc. The goal is not to exercise perfectly, but make it a part of everyday life. 

Dr. Kawahara noted that AI is advancing at an extraordinary speed. Today, knowledge, advice, and even encouragement can be delivered digitally. At the same time, it can sometimes feel that our bodies are being left behind. However, in the age of AI, the importance of the body may be increasing even more. She asked how people should think about the body in the era of AI and what role the body plays in maintaining well-being, motivation and the ability to act. 

Dr. Sasaki responded that AI can provide information and personalized recommendations, and even coaching. However, AI cannot replace biological effects of physical movement. Exercise and physical activities change our muscles, brain functions and cardiovascular system and metabolism. These physiological changes influence not only physical health, but also mood and motivation. Therefore, although AI should not replace exercise, it can become a powerful tool that helps people adopt healthier behaviors and maintain them over time. 

A student asked about the current understanding about the relationship between muscle, physical strength and a person’s willingness to live actively. 

Dr. Sasaki responded that the relationship between muscle and willingness is known about but not fully understood. Exercise has been shown to improve symptoms of depression and anxiety, however, motivation is influenced by many factors, including psychological and social factors. Muscle strength alone does not determine motivation. An exciting area of current research is how exercise influences the brain through hormones and other signals. It is likely that over the next decade more will become clear as research progresses. 

Dr. Kawahara noted that the research project based on exercise in cancer care will begin by collecting data in Japan, building a solid foundation, and then expanding into a collaborative study with Malaysia.

This project was born through this lecture series and it will be nurtured carefully and developed into a meaningful international collaboration.

One of the most important themes discussed repeatedly in the lecture course is how cancer patients can return to society after treatment. This is not only a medical issue. It is also a question of rehabilitation, work, family life, social participation, and dignity.

In particular, exercise for the prevention of cancer recurrence is closely connected to the concept of “return to work.” It asks us how we can support patients not only to survive, but also to recover strength, regain confidence, and participate again in society.

Dr. Kawahara noted that the lecture today had provided a very concrete example of social implementation. It demonstrated how clinical knowledge, patient support, behavioral change, and institutional design can be connected in a real-world pathway.