What do these entities all have in common?

Unless you looked at the tags for this post, you will probably be surprised to hear that they all have departments dedicated to behavioral science. From the U.K.’s national behavioural insights team, to the FBI’s Behavioral Science Unit, to our own Behavioral Services team, there are specific groups dedicated to figuring out what makes people tick. As someone who has always been interested in the quirks of human behavior, I am fascinated to see the variety of problems that are being solved with behavioral science research:

• Reducing energy consumption on a national scale
• Helping patients with chronic conditions to have a better healthcare experience
• Convincing people to pay their taxes
• Helping law enforcement agencies to better understand criminals

This is all to say, our task of using behavioral science to take over the world is almost complete. Mwahahahaha!

What do parents, teachers, doctors, and public health professionals have in common?

We all want kids to eat healthy foods.

Those of us interested in school nutrition have been fighting for decades to get healthy lunches available in schools. Unfortunately, things things don’t always go our way. (In what universe is pizza a vegetable?) Then there is the challenge from school boards who are convinced that vending machines are the key to their financial viability. Some schools have actually been able to remove unhealthy options from the cafeteria… resulting in kids bringing chips from home in record numbers. It sometimes seems like we just can’t win here, and the reason is simple:  We, kids and adults alike, do not like to be told what to do.

Enter classic behavior modification techniques and the power of choice. You may be surprised to learn that there are a few simple and interesting strategies to encourage healthy eating. Read on to learn how to prevent kids from rebelling against healthy lunches, and to build their skills choose healthy options in the future.

• Apples on impulse

Rather than keeping candy bars, chips, and other less desirable snacks near school cafeteria cash registers, put fruits and vegetables there. That way, impulse buyers will be choosing from a healthier set of options.

•  Shifting the salad bar

In many school cafeterias, salad bars are pushed off to the side so students have to go out of their way to select this option. One school moved the salad bar to the middle of the cafeteria so that kids had to walk around it to get to the cash registers. They subsequently saw a 21% increase in salad sales.

• Carrots or cauliflower?

When students are given a choice of which vegetable they eat, food waste decreases and vegetable consumption increases. What more could a fiscally and nutritionally conscious school board want?

So there you have it. Getting kids to eat broccoli is easy. You just have to convince them that it was their idea.

Dismayed television viewers collectively sucked in their breath — and their stomachs — when former White House doctor Connie Mariano chose an all-too-public forum for her fears that New Jersey Governor Chris Christie might “die in office” because of his weight. I couldn’t help thinking how different that unfortunate moment might have been if Dr. Mariano had used behaviorally sound strategies to deliver her message more effectively.

Late-night jokes and running pun-laden headlines aside, Dr. Mariano no doubt has Gov. Christie’s best interests at heart. Although it is doubtful she routinely uses that sort of alarmist language in the exam room with her patients, the episode demonstrates why well-meaning and even urgent healthcare advice goes unheeded by patients. Gov. Christie’s strident rebuke of Dr. Mariano also dramatically illustrates the emerging power of the patient and the changing doctor-patient dynamic in this age of healthcare reform.

During a press conference, after saying Dr. Mariano should “shut up,” Gov. Christie said he has a plan for dealing with his weight, adding, “My doctor continues to warn me that my luck is going to run out relatively soon, so believe me, it’s something I’m very conscious of.”

A behavioral science–based approach might have helped Dr. Mariano view Gov. Christie’s awareness of his blood pressure and blood sugar levels (normal, according to him when he appeared on Letterman) as positive indicators for change. His “luck” terminology could indicate a belief he has little control over the situation. Rather than jumping to negative conclusions, if  Dr. Mariano was armed with the proper insight, she could have employed positive framing, and used an approach that tapped into Gov. Christie’s heath behavior drivers that might motivate him to take action.

Instead, the dramatic public backlash, which played out on the political stage shows how there continues to be a gap in communicating and managing chronic conditions. Dr. Mariano’s cringe-worthy comments, along with Gov. Christie’s outrage and subsequent good humor and surge in the polls to a 74% approval rating need little analysis. What they do require, however, is recognition that it takes more than good advice to move patients toward positive lifestyle change. In today’s complex (not to mention politically charged) healthcare environment, it’s not enough for doctors to diagnose the problem and provide information. Patients demand a greater say in their own care, and everyone involved is being held accountable for better patient outcomes. Fortunately, doctors can use effective patient-centric approaches to help patients overcome barriers to improving those outcomes.

So lately I’ve been thinking a lot about rewards and health. There’s been a lot about “gamification” in the press lately. I am really not one to jump on bandwagon. I guess I am just more curious than anything. Being in the behavioral science field for 13 years –I have always had the strong opinion that games and rewards don’t drive lasting behavior change. The motivation and drive must come within in – an individual must want to change for it to happen. A little reward here and there can’t roll a rock uphill.

But here I am at a point in my own life where I really do want to feel good, have energy and be healthy. But I’ve just got too much to do. Exercise comes last. Well, let’s be honest, exercise doesn’t come at all for me. I have no intrinsic motivation. There’s always some laundry to fold, a lunch to make, a client meeting to prepare for – or “I just have to stay in bed 20 more minutes to function.” My list of excuses (some of them legitimate) could go on, but I won’t bore you with the details.

So I’ve been thinking – maybe there is something to gaming and health. Maybe I am one of those people who just need a little push on a daily basis. Maybe a thumbs up or smiley – just a little positive reinforcement – would break through my inertia (AKA daily chaos) and cause me to re-prioritize.

So, I am going to conduct my own personal experiment over the next couple of months. I am going to ask some of my more technology-savvy friends and colleagues to recommend for me some sort of digital exercise tool that incorporates rewards or gaming. Not that n=1 is a proof point. But it is a starting point.

This week I had the opportunity to host an internal Sparkology session. Sparkology is our agency’s internal forum for cross-sharing ideas and expertise – and it’s also a great opportunity for free lunch and to hang out with some pretty cool people that I don’t get to see every day.

The focus this week was on behavioral science – taking a look at the history of behavioral science and examining the innovative ways that our agency is applying this health behavior expertise to develop campaigns that drive positive patient outcomes.

We looked at examples of marketing campaigns –and peeled back the layers to look at not just the insight behind the campaigns, but also how behavioral science provided practical strategies for changing both patient and healthcare professional behavior.

Below are highlights of our discussion that summarize how applying behavioral science is innovative, relatable and practical:

Innovative

• Behavioral science is old, but not that old if you compare it to astronomy – it’s only been around since the 1930’s-40’s. We tap into decades of proven strategies from behavioral science to craft solutions that are relevant to today’s healthcare landscape.
• Behavior is complex and solutions that drive lasting behavior change need to challenge conventional thinking – for example, information alone won’t change behavior.

Relatable

• Behavioral science is relatable…
  • Kim Kardashian, Albert Bandura, Diane Parrott, Jo Frost, B.F. Skinner and Dr. Cliff Huxtable are all behavioral experts according to our poll – I won’t reveal which one received the highest rating.
  • Internally, we all have behaviors that we know we should engage in more often – flossing teeth, calling parents and praying were top mentions.
  • Behavior comes down to choices – some voluntary and some involuntary – that are driven by an interplay of beliefs, motivators and our environment.

Practical

• We explored some recent MicroMass and outside-industry work that demonstrated use of behavioral techniques such as experiential learning, cues to action, motivational interviewing and problem solving.

And I will leave a parting thought that I did not share at Sparkology – applying behavioral science is not boring. Take a look at this innovative initiative which uses cues to action (and humor) – putting a prompt or cue in the environment to change a behavior – in this case, to slow down speeding cars.

Now that’s what I call resourceful!

The goal of game mechanics and game dynamics is to drive a user-desired behavior predictably. The same ideas apply to human health behavior and the application of behavioral models and frameworks in health intervention design. This requires an understanding of how humans behave. This is where all those behavior models come into play.

There are many such models and frameworks, each useful in specific contexts. A model/framework is chosen based on whether it can give us the understanding we need to address the particular problem.  Specifically to game dynamics and game mechanics, we can use the multi-factor model behavior model by J. Fogg of Stanford University known as Fogg’s behavior model (FBM). FBM asserts that there are three required factors that underlie any human behavior:

• Motivation (the want or desire to do something )
• Ability (the necessary resources)
• Trigger (the ‘spark,’ ‘signal,’ or ‘facilitator’)

According to FBM, these factors must converge at the same time to successfully drive a behavior. Any temporal misalignment in these three factors will degrade effectiveness. FBM also asserts that for the target behavior to happen, users usually require a minimum level of ability and motivation called the activation threshold for the behavior. When the trigger (something that prompts or tells the users to carry out the target behavior now) is introduced at the right time (above the activation threshold), the user is lead to the inception of the predictable behavior.

Of course, more than one behavior model or framework can be applied to a health intervention. For example, we can leverage the Power Law of Practice into a task-based intervention. The Power Law of Practice states that people make fewer errors and are faster with the more time they spend doing the task. About 80% of improvement along the power function comes from figuring out a good strategy for getting the task done, while about 20% of improvement comes from getting better at the same strategy.

There is good evidence that the steep part of the power function is actually composed of a combination of step functions where each step is a learning event – where one acquires new knowledge or develops a better model for how the system works. An intervention designer needs to understand what learning events occur so that individuals don’t get stuck and stop using the technology or some of its features.

From a motivation perspective, we can utilize a model by Daniel Pink. Pink hypothesizes that in the modern society where the lower levels of the Maslow’s hierarchy are more or less satisfied, people become more and more motivated by other intrinsic motivators, specifically: autonomy, mastery and purpose. From a game dynamics perspective, purpose is satisfied by quests, discovery, epic meaning; mastery is satisfied by points, progression and levels.

As you can see, when the appropriate behavior models and frameworks are applied a health intervention, behavior change can occur in a more effective and predictable manner.

Dr. Charlene Quinn, from the NIH’s Office of Behavioral and Social Sciences Research, put it this way in her recent spotlight video (you can watch below) concerning mHealth in diabetes management: “There are thousands of applications calling themselves mobile health, but very few of those applications actually have science behind them…”, which includes the clinical data, the evidence, they actually work.  She concludes by saying: “We really need to think through not only data and numbers, but what behaviors, using mobile health or mobile technologies, most encourages people to change their behavior, improve their health, and ideally improve the health of a population.”

That got me to thinking about what fundamental characteristics that an mHealth intervention needs to have to be successful in changing a patient’s behavior.  Many of these characteristics are simply good design principles: understanding the patient, knowing the socio-ecological system and sub-systems, iterative design and implementation. In general, simple messages delivered at the right time in the right place that are tailored, non-disruptive and repetitive and consistent is a sound way to think of how to build an mHealth intervention. The nature of portable computing with mHealth gives us the right place (where the patient is). Characteristics for a behaviorally-based mHealth intervention also require the ability to detect points of decision, behavior, and consequence and mobile devices require attention to interface design.

One important thing to consider is that sensors sometimes lose contact or run out of power or the wireless network is interrupted. Additionally, patients may willfully disable senor devices or not log the data or be as truthful as they should.  What then? Statistics can play a big role with imputation techniques (procedures are designed to fill in the missing data gaps), but there can be legal, privacy and medical issues and is a topic for another day.

So as we think about both the advantages of mHealth (ability to observe multiple and repeated levels of behavior as it happens in naturalistic settings) we must also consider some of the issues (missing data, good user experiences, privacy, etc.) as well.

It’s December. That means in just one month it will be a new year. And with a new year comes the ever popular New Year’s resolution. Whether it’s to stop biting your nails, exercise more, eat healthier food, or spend less money on clothes and shoes you don’t really need, it’s a commitment you’re making. And as we all know, just because you make a commitment doesn’t mean you’ll keep it. In fact, Dr. John Norcross, a psychology professor at the University of Scranton, indicates that only 40% to 46% of “New Year’s resolvers” will actually be successful after six months. That means more than 50% of those who desire to make changes won’t achieve success.

If you do plan to participate in this popular New Year’s activity, try to make an effort to set achievable and realistic goals for yourself. You can do this by setting SMART goals. These are goals that are specific, measurable, attainable, relevant, and timely.

For example, If you’re interested in exercising more, your goal shouldn’t just be, “In 2013, my goal is to exercise more.” Instead, include additional details that are not only realistic for you given your schedule and desire, but also measurable. An example of a SMART goal is, “In 2013, I will go to the gym 4 days a week for 45 minutes each day.” And don’t be afraid to adjust your goal if you find it’s too lofty. Sometimes schedules can get in the way. This doesn’t mean you should give up. It just means you need to make some changes so that you’re working towards something more feasible.

This year, in addition to breaking that nail biting habit, make a commitment to fall into that select group of 46% that is successful.

Take Two Apps and Call Me in the Morning

It may not be too long in our future when part of a prescription from our physicians may include and app (or two). This is the exciting idea of medically prescribed apps. Some futurists predict that doctors will prescribe FDA-approved apps to treat patients. So far, the FDA has maintained that it will only vet apps that perform device-like functions, such as making diagnostic determinations or treating ailments. The FDA has yet to release its full guidance on the regulation of mobile apps and will not go after the many available downloads that make untested medicinal claims until its rules are in place.

WellDoc is one of the pioneers in the prescription-app field. Its DiabetesManager system collects biometrics about a patient’s diet, blood sugar levels and medication regimen through manual input or from wireless devices. It then gives advice to a patient and sends clinical recommendations to the doctor. The Food and Drug Administration gave the system 510(k) clearance to operate as a medical device in 2010.

Happtique (health app boutique) is a company that operates a mobile app prescribing solution for healthcare called mRx. Happtique has recently launched a pilot that will test whether the company’s solution will encourage doctors to prescribe mobile software for patient use. mRx consists of Apple and Android smartphone and tablet compatible apps that focus on cardiology, rheumatology, endocrinology, orthopaedics, physical therapy and fitness training. The mRX system gives patients more structured guidance when it comes to selecting and using health apps and empowers them with tools to help them take a more active role in their care. And similar to traditional prescription, mRx will track how many times an app is prescribed as well as how many times patients click the “fill” button once the prescription is sent.

If the mRx trial is successful, it will help demonstrate that mHealth technology will be viewed as legitimate, powerful healthcare tools, not just fun programs to install on a phone or tablet.

From a behavioral point of view, the WellDoc and mRx systems can help encourage a dialogue between physicians and patients about available healthcare technology tools. These conversations will not only give patients additional resources, but will also encourage them to consider incorporating apps and other healthcare technology into their health management. In addition to increased health care provider connectedness, these systems also help achieve behavioral change and continued adherence through sustained influence over the patient’s multiple chronic states and enhanced patient self-determination.

When you think about it, these apps are no different from physicians prescribing a diet, a support group or any other resource. In fact, these apps will enable physicians to be more creative with the ways they engage their patients and provide the best care to them.

Last week I had the privilege of spending two days with diabetes experts in Washington, DC at the American Diabetes Association’s 5^th Disparities Partnership Forum.

The goal of the conference was to provide a forum for discussion around the onset of type 2 diabetes in high-risk populations. One of the many populations discussed was women. Brandy Barnes, the Founder and CEO of DiabetesSisters, and I submitted an abstract to the ADA highlighting the unique needs of women living with diabetes and it was selected as one of two Promising Practices to be presented at the conference.

I was so excited about being able to share the work of MicroMass and DiabetesSisters with an audience of experts who are all genuinely interested in understanding how to positively influence women with diabetes. Creating sustainable behavior change is critical, and I know together our organizations are already making great strides.

Andi Weiss presents at The 5th Disparities Partnership Forum from MicroMass on Vimeo.