Behavior Change: What can we learn from other industries? – EXAMPLES

I was just in California with an esteemed advisory group of Kaiser Permanente and national experts to plan for a larger discussion about behavior change to happen in 2013. It is one of the benefits of working in an integrated health system that we (a) think about these things (b) reach out to others to think about them with us. One of the experts with us was Michael McGinnis , who asked me to share my slides, so I’m doing that here.

I tend to avoid text on my slides, so they won’t make a lot of sense unless I do text narration, so I’ll do that, here goes, let me know what you think. Adds, subtracts, feedback welcome.

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Slide 1: Title. Photograph taken by me, at a startup event in Washington, DC, featuring one of the region’s hottest startups, OPOWER (@OPOWER)

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Slide 2: The pitch. One outcome of a discussion about behavior change among health systems is to partner with industries that have been successful in enabling behavior change. There are examples out there, which I’ll show in the following slides. These examples use science in their approaches, that we don’t use in health care.

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Slide 3: The framing of what we’re looking for, by my mentor David Sobel, MD. We’re not looking for examples where other industries have motivated people, we’re looking for examples where industries/organizations have triggered and created environments that made the change easier. Those examples exist.

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Example 1. What’s wrong with this hotel’s attempt to get guests to reuse towels? Quick answer – it doesn’t use science. The image of mother earth does not stimulate people to change their recycling behavior. In studies, when cards said “the majority of guests in this hotel recycle their towels,” reuse increased 26 %. When the cards said, “the majority of guests staying in this room reuse their towels,” the increase was even higher, 33 %. This is based on the impact of relevant peer comparisons, and creating positive social norms. (Source info: Now Reading: Yes!: 50 Scientifically Proven Ways to Be Persuasive (many analogies to health care) | Ted Eytan, MD)

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Example 2: OPOWER (@OPOWER) This company has taken the science of positive social norms and relevant peer comparisons, and worked with a large, less nimble industry, utilities, to change behavior. By including information in utility bills that indicate how each household is doing with energy use relative to other households in its neighborhood (this is key #1), and a normative evaluation like a frowny face ( this is key #2), there are marked decreases in energy use, after just 4 weeks. This is a great example for health care, because it’s a company with nimble tools interacting with a large, less nimble industry. It’s also been discovered that if a household is actually lowest in energy use in a neighborhood, that if you put a smiley face evaluation, that household may begin to increase its electricity use – so lesson is to use the smiley face carefully! (Source info: Now Reading: The @OPOWER experience – peer comparisons can reduce energy usage, and other industries may understand behavior as well or better than health care | Ted Eytan, MD)

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Example 3: Voting. This story from NPR talks about how the “voting industry” (is that an industry?) achieves targeted success by using some of the same scientific techniques, like positive social norms, and re-enacting the change (“tell me about how you’ll vote on election day”). Note that they have also costed out each approach in fine detail. Do we do this in health care? Do we talk to women and say, “Tell me how you will go about getting your mammogram when it is due.” (Source: Can Science Plant Brain Seeds That Make You Vote? : NPR)

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Example circus: Left to Right: Reports from the British Institute for  Government and Cabinet Office (See: Applying behavioural insight to health | Cabinet Office and About MINDSPACE online | mindspace online) exploring behavioral science and health, which included lessons form other industries. The shopping cart example is interesting – placing yellow tape midway across the cart and marking one half with “fruits and vegetables” immediately changed purchasing behavior. An article from The Economist is on the far right (see: Sex and advertising: Retail therapy | The Economist), talking about how science is used to promote unhealthy behaviors, through the use of technologies like functional MRIs (one day I hope to have one in my living room), that assess the neurochemistry of eating snack foods. On the upper right, consultancy Ideas42, that specializes in behavioral economic approaches to behavior change, across industries….except health (it’s grayed out on their web site).

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Example from the British Institute for Government and the Cabinet Office applying this work to health care (See: Influence At Work / BDO ‘Did Not Attend’ (DNA) Studies | mindspace online) . A simple sign in the waiting room that set a positive social norm (“94% of our patients attended their appointment on time last month”) instead of one that set a negative norm (“67 patients failed to to keep their appointment last month), brings much better results.

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Where it says “Active Commitment + Normative Message,” this is a situation where the patient, instead of the receptionist, writes down their next appointment time, along with the simple sign in the waiting room discussed above. As discussed in the MINDSPACE work, the goal was to intervene in a no-cost way.

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“Maria” is not a real person. She’s a validated persona based on actual clinical and other data – an educated Latina woman who seeks more than allopathic (traditional) medicine in her care for a more holistic experience. The questions on the right ask about the use of science based behavior change techniques in health care:

Do our patients get a monthly “health statement” comparing their health progress to the other patients in their personal physician’s practice? (e.g. “87 % of the women in your physician’s practice have received their mammograms on time, frowny face, you are behind.”)

Do our patients have the ability to access data about the practicing patterns of clinicians across a medical group to find the physician with similar clinical interests (e.g. “These physicians are more likely to prescribe complementary treatments for uncomplicated back pain.”)

Could our patients be guided through the actual moment of a new behavior? (e.g. “Let’s talk about what will happen when you decided to get your mammogram.”) (This was referenced in the NPR piece above on voting)

At this point I’d like to thank a few influencers in my thinking including Sophie Raseman (@raseman), David Sobel, MD, who caused me / connected to a lot of other great influencers, like BJ Fogg (@bjfogg) and colleagues at the Kaiser Permanente Care Management Institute and Institute for Health Policy. Much much more to learn and share, and I’ll post that here.


@chimoose thanks, Greg! I will keep the earth posted on our progress setting up this conversation.

Fantastic post, Ted! As a fan of OPower for some time, intersectingsocial marketing, social networking and graphic design is wherehealthcare must go. Boldly. also for healthcare team members! How about:90% of providers responded to secure email within 24 hours.90% of residents ask patients to sign up for online access to their information:-)

Sue Woods Hello Sue, Uh, I just found this comment in my spam filter, maybe because of the link, so allow me to properly connect readers to you work, dated 2 years (!) ago, Dr. Ahead-of-Her-Time, . Apologies and yes, agreed, there are too many signals in health care that are framed in the negative, like “you didn’t answer your messages on time,” versus “99 % of you answered your messages on time.”
I just had a conversation with two OB/Gyns at Kaiser Permanente and we all agreed on one thing about the culture, and that is that when we see the folder on the EHR that says, “Patient Secure Messages” has messages in it, we go to that one first, over all the other messages that are waiting (and there are usually a lot). That’s powerful reinforcement of the value of the patient story.
Hey are you going to come to this behavior change summit in May, 2013, in Washington, DC? Just asking,

SueWoods Ted Eytan barrytwoods Sue Woods Sue, That’s an interesting question. What could we learn from the renewable energy industry that we are not using in health care? Examples please,

Great post, and an area I’m developing a growing interest in. As a technology professional, I’m intrigued by the enabling role that technology can play in using behavioral change to positively impact health outcomes. Will stay plugged in to your blog in the hopes of learning more!

Ted Eytan, MD