We live in an age where most of the pressing health issues we face as a society can be linked directly or indirectly to underlying social and behavioral determinants. These two issues present not only significant challenges to healthcare providers but also to payers seeking cost-effective ways to manage population health and provide value. Supporting people in living healthier lifestyles is, therefore, a fundamental concern for both affected and at-risk populations as well as for healthcare payers, providers, caregivers, and governments. But how do we best support people in adopting and sustaining health promoting and protective behaviors, and reducing or avoiding health-risk behaviors over the course of a lifetime? The answer, lies of course, in the ever-maturing science of behavior change. The past decade has materialized a renaissance of theory-and-evidence-to-practice approaches that focus not only on identifying ‘what works’ when it comes changing behavior for a given problem, population, and context but also on how these techniques can be used to deploy interventions through any channel to change behavior and achieve meaningful outcomes. This webinar will present an overview of the essential components of modern, applied behavioral science, and a process model for the design, implementation, and evaluation of effective behavior change interventions.

1. Behavior Change Design
A Comprehensive Yet Practical Approach
to Achieving Health Outcomes
Dustin DiTommaso | SVP, Behavior Change Design | @DU5TB1N
Nov 2020

2. House Keeping
✫ A PDF of the slides are posted in the
GotoWebinar “Handouts” pane.
✫ Questions will addressed at the end of the
webinar.
✫ Feel free to add yours anytime during the talk
in the “Questions” pane.
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3. An Opening Proposition
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Human behavior
(& behavior change) is
central to achieving
health outcomes.
Improved health, functioning, quality of life (QOL), quality
adjusted life years (QALY), reduced healthcare costs

4. Determinants of Health
It has been estimated
that individual behavior
contributes to 40% of all
health outcomes.
40%
20%
10%
30%
INDIVIDUAL
BEHAVIOR
SOCIAL /
ENVIRONMENTAL
GENETICS
HEALTH
CARE
HEALTH &
WELLBEING
A focus on changing behavior remains an imperative
strategy for reducing the rising burden of long-term
conditions and health inequalities at scale.
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5. Primary, Secondary, & Tertiary Prevention
Health Behavior Categories
✫ Behaviors that contribute to the prevention of disease
✫ Behaviors that relate to the delivery of healthcare
✫ smoking cessation, diet changes, physical activity, stress mgmt.
✫ vaccinations, screenings, medication adherence, condition mgmt.
✫ prescribing behavior, referrals, uptake of evidence-based guidelines
✫ Behaviors that relate to the adoption and usage of
health technologies
✫ Behaviors that involve care-seeking and adherence
to treatment
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6. A Network of Behaviors
Who Needs to Do What?
✫ Members / Patients
✫ Providers / Clinicians
✫ Caregivers / Significant Others
✫ Payer Staff
✫ Provider Staff
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7. What Is Typically Done?
Provide Information
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Right Information, Right Time
is a Good Start.
Information is often essential
but not sufficient.
What about those who know
what to do and how to do it,
but do not or cannot?

8. What Is Typically Done?
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Nudge Them
Can be useful for one-off or
‘in-the-moment’ behaviors.
Health outcomes typically
require sustaining behaviors
consistently over the long-
term.

9. What Is Typically Done?
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Scare Them
Dodgy results. Only work for
some people, in some
circumstances, for some
behaviors.
Without clear action plans to
change and the confidence to
succeed, many people
respond with defensiveness.

10. What Is Typically Done?
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Can be an effective strategy
for one-off or short-term
behaviors. Especially for
deprived populations.
Cost-effectiveness isn’t clear.
Behaviors stop after the
incentive is removed.
Are you willing to pay forever?
Pay Them

11. Understand Behaviors in Context
PROBLEM SOLUTION
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12. PROBLEM
UNDERSTAND
+ FRAME IN
BEHAVIORAL
TERMS
SOLUTIONPRODUCEANALYZE
Understand Behaviors in Context
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13. Toward an Integrated Science of Design
Behavior Change Design
SOCIAL &
BEHAVIORAL
SCIENCE
HUMAN-
CENTERED
DESIGN
DATA
ANALYTICS
Integrating design and technology
with scientific methods and
frameworks to design, implement,
and evaluate interventions that
change real-world behaviors.
@DU5TB1N |
Founded 2009

14. 4 Phases of Behavior Change Design
Diagnosis: Understand & define the problem/opportunity space
Prescription: Define how you will address the problem/opportunity
Execution: Design & implement your solution
Evaluation: Measure effects to understand what works and why
1
2
3
4
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15. Understand & Define the
Problem / Opportunity Space
Define Intervention Strategy
Evaluate throughout the
Design Process from Ideation
to Impact
Iterative Design of System
Components & Scaled
Implementation
DIAGNOSIS PRESCRIPTION EXECUTION EVALUATION
BCD Methodology
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16. Outcome
Behavior
Actor
Behavior
Behavior
Actor
BehaviorActor
Behavior
Behavior
Behavior
Behavior
Behavior
Identify the Population & the Behaviors
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Diagnosis: Define the Behavior/s
- Have identified the range of relevant
behaviors and who is performing them.
- Narrow in on the behaviors most
appropriate to intervene upon – in a
systematic not scattershot approach
- Specify in detail who needs, to do what, to
what extent, and in what contexts for
outcomes to occur.
We want to:

17. Reduce Salt
Intake
Increase
Potassium
Intake
Take
Medication as
Prescribed
Increase
Physical
Activity
IF Smoking
Stop
Decrease
Sat. Fat &
Cholesterol
Lower
Hypertension
People with Hypertension will
improve their self-management
Not Helpful
Diagnosis: Define the Behavior/s
Increase the number of patients with
Stage-2 and above hypertension who
take their medication every day at the
correct time, as prescribed by their
MD, and measured via self-report.
Helpful
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18. Diagnosis: Define the Behavior/s
WHO:
WILL DO WHAT:
TO WHAT EXTENT:
IN WHAT CONTEXT:
Target Audience (or supporting actor)
Target Behavior
Engagement Pattern (frequency, duration, intensity)
Where, when, with whom, to whom, etc.
Behavioral Statement
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19. Diagnosis: Understand the Behavior in Context
✫ Because they are tired?
✫ Because they are hungry?
✫ Because there was a creepy bug
across the table?
✫ Because there is nothing good on
the menu?
Why is this toddler
behaving this way?
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20. ✫ The same behavior (e.g., a
tantrum) may be caused by
many different factors.
✫ Successfully dealing with the
behavior (i.e., changing it)
depends on having an
accurate understanding of
the causal factors.
Diagnosis: Understand the Behavior in Context
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21. Understanding Behavior in Context
✫ What needs to change within the person
or their environment for the desired
behaviors to occur?
Answering this is helped by a model of behavior.
✫ Why are behaviors as they are?
Ask Yourselves:
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22. COM-B Model for Understanding Behavior
Behavior
Michie et al (2011) Implementation Science
Behavior occurs as an interaction
between three necessary conditions
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23. COM-B Model for Understanding Behavior
BehaviorMotivation
Opportunity
Capability
Psychological or
Physical ability to
enact the behavior
Reflective and Automatic
mechanisms that activate or
inhibit behavior
Physical and Social
environment that enables
or constrains behavior
Anything a person does
in response to internal
or external events
Michie et al (2011) Implementation Science @DU5TB1N |

24. Defining Capability
Capability
Psychological or
Physical ability to
enact the behavior
Physical Capability
Having the skills, strength, or
stamina to perform the behavior
✫ e.g. taking blood; administering
injection; being physically able to
run a 5k
Psychological Capability
Having the necessary knowledge and
mental capacity to make decisions
and regulate your own behavior
✫ e.g. knowing what foods will raise
blood sugar levels; not being so
overwhelmed with information that
you can’t make healthy choices
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25. Opportunity
Physical Opportunity
Aspects of the environment that
promote or prevent behavior
✫ e.g. having a safe space locally
to go running
Physical and Social
environment that enables
or constrains behavior
Defining Opportunity
Having the resources needed to
perform the behavior
✫ e.g. having the money to afford
fresh fruits and veggies
Social Opportunity
Interpersonal factors that
influence behavior (such as
social norms)
✫ e.g., drinking more because
those around you are drinking
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26. Motivation
Reflective Motivation
Beliefs about what is good and
bad, conscious considerations,
intentions, and plans
✫ e.g., weighing up the pros and
cons of a behavior; making a
goal to improve your eating
habits
Automatic Motivation
Emotional responses, desires and
habits resulting from associative
learning and physiological states
✫ e.g., eating all the tacos because
they taste so damn good;
drinking wine while cooking out
of habit
Defining Motivation
Reflective and Automatic
mechanisms that activate or
inhibit behavior
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27. Sources of Evidence
During your diagnosis phase conduct research to understand the determinants of target behaviors
Literature Review Qualitative Research Run a Survey
Academics will have likely
already done a lot of the
leg work: Look at the
literature to see what
they found.
Conduct interviews to
understand the
behaviors in context
Once you have ideas
about potential
influencers, run a
survey to help you
prioritize.
@DU5TB1N |

28. COM-B Analysis Coding
I say to
“There are so many things
I’m trying to change since
my diagnosis – it’s easy to
forget to take my meds.”
Increase the number of patients
with Stage-2 and above
hypertension who take their
medication every day at the
correct time, as prescribed by
their MD, and measured via self-
report.
Psychological Capability: Memory, Attention, Decision Making
@DU5TB1N |

29. Asthma Care Plan: COM-B Analysis {Example}
HEALTH
ACTION
CAPABILITY MOTIVATION OPPORTUNITY
PHYS PSYCHOLOGICAL REFLECTIVE AUTO SOC. PHYSICAL ENV.
PHYS
SKILLS
KNOW
LEDGE
PSYCH
SKILLS
M.A.D BEHAV
REG.
INTEN
TIONS
GOAL BELIEF
CAPES
BELIEF
CONS
IDNTY OPTM EMOT SOC
INF
CTXT REINF
Create Asthma
Action Plan w.
Provider
Carry Rescue
Medication at All
Times
Use Inhaler
Properly In All
Conditions
Avoid Asthma
Trigger Events
Track Your
Symptoms
Check Peak Flow
as Directed by
Provider
@DU5TB1N |

30. Asthma Care Plan: COM-B Analysis {Example}
HEALTH ACTION CAPABILITY MOTIVATION OPPORTUNITY
Create Asthma Action Plan w. Provider Cap-Psy: Knowledge New members did not
know purpose or benefit of asthma plan
Cap-Psy: Memory, Attention Members did
not bring in/bring up action plan with
provider with sufficient time to address it in
the appointment.
M-Ref: Beliefs about Consequences
Members do not believe that Asthma Action
Plan is sufficiently tailored to their needs.
This may be because they believe their
asthma is not sufficiently severe to require
an action plan, that they do not accept the
recommended treatment (especially amount
of medication), or that the Asthma Action
plan is too generic to be helpful.
Opp-Ph: Social Influence Providers are
familiar with prescribing Asthma Action
Plans and endorses use for members.
Carry Rescue Medication at All Times Cap-Psy: Memory, Attention Members
reported difficulties in remembering to take
rescue inhaler with them wherever they go.
Cap-Psy: Knowledge Members didn’t
understand when and how to use long-
acting/controller medication.
M-Ref: Beliefs about Consequences Some
members did not believe the benefits of
using the controller medication are worth
the costs. They worried about monetary
cost, side effects, medication dependence,
and/or that medication effectiveness will
diminish over time. They may also wish to
minimize the number of medications they
are taking if they have other chronic
conditions.
Use Inhaler Properly In All Conditions Cap-Psy: Knowldedge Many Members did
were unsure if they were using their inhaler
correctly, and on demonstration were in fact
using it incorrectly.
Opp-Pys: Resrouces Inhaler should be quick
and easy to use during an exacerbation
(easy-off cap, portable)
Consider offering options for other type of
inhaler device, or using medications that can
be taken with one inhaler device. Some
members may benefit from home use of a
small volume nebulizer (SVN).
@DU5TB1N |

31. Prescription: Define How You Will Address the Problem
INTERVENTION FUNCTIONS
Intervention functions are
broad categories of
intervention strategies
Selection is informed by
COM-B Analysis
Example: Education, Training
SELECT
BEHAVIOR CHANGE TECHNIQUES
IDENTIFY
INTERVENTION COMPONENTS
TRANSLATE & APPLY TO
Intervention functions are
delivered by one or more
Behavior Change Techniques
(BCTs)
BCTS are the Active Ingredients
of a behavioral intervention
Smallest reducible component,
designed to change behavior
Example: Goal-Setting, Feedback
BCTs have Design Implications
for how they will be applied to
human-technology-service-
interactions, content and
messaging and how they will be
delivered through different
channels, touchpoints, and
interface elements.
Example: Weekly Progress
Email, Text-Message Reminders
@DU5TB1N |

32. Education
Increasing knowledge or understanding

33. Training
Imparting skills necessary to perform
target behaviors

34. Needs satisfaction
Satisfying basic psychological needs of autonomy, competence,
and relatedness

35. Persuasion
Using communication to induce positive or negative feelings or
stimulate action

36. Incentivisation
Creating an expectation of reward

37. Coercion
Creating an expectation of punishment or cost

38. Restriction
Using rules to reduce the opportunity to engage in the target behavior

39. Environmental Restructuring
Changing the physical or social environment

40. Modeling
Providing an example for people to aspire to or imitate

41. Enablement
Increasing means/reducing barriers to increase capability (beyond education
and training) or opportunity (beyond environmental restructuring)

42. 10 Intervention Functions Linked to COM-B Factors
Education
Training
Persuasion
Needs
Satisfaction
Incentivization
Coercion
Restriction
Environmental
Restructuring
Modeling
Enablement
COM-B Factors
Physical Capability
x x
Psychological Capability x x
Reflective Motivation x x x x x
Automatic Motivation x x x x x x x x
Physical Opportunity x x x x
Social Opportunity x x x x
@DU5TB1N |

43. Behavior Change Techniques
But HOW will you educate, persuade,
enable, etc.?
Intervention functions are made up of component
Behavior Change Techniques (BCTs)
§ “Active Ingredients” of a behavioral intervention
§ Smallest components that change behavior
- Goal Setting
- Action Planning
- Self-Monitoring
- Feedback on Behavior or Outcomes
- Demonstration of Behavior
- Rewards (social, material)
- Commitment
- Graded Tasks
@DU5TB1N |

44. Michie, et al. 2013
Goals and Planning
1.1. Goal setting (behavior)
1.2. Problem solving
1.3. Goal setting (outcome)
1.4. Action planning
1.5. Review behavior goal(s)
1.6. Discrepancy between current
behavior and goal
1.7. Review outcome goal(s)
1.8. Behavioral contract
1.9. Commitment
Feedback and monitoring
2.1. Monitoring of behavior by others
without feedback
2.2. Feedback on behaviour
2.3. Self-monitoring of
behaviour
2.4. Self-monitoring of
outcome(s) of behaviour
2.5. Monitoring of outcome(s)
of behavior by others without
feedback
2.6. Biofeedback
2.7. Feedback on outcome(s) of behavior
Natural Consequences
5.1. Information about health consequences
5.2. Salience of consequences
5.3. Information about social and
environmental consequences
5.4. Monitoring of emotional consequences
5.5. Anticipated regret
5.6. Information about emotional
consequences
Comparison of behavior
6.1. Demonstration of the behavior
6.2. Social comparison
6.3. Information about others approval
Associations
7.1. Prompts/cues
7.2. Cue signaling reward
7.3. Reduce prompts/cues
7.4. Remove access to the reward
7.5. Remove aversive stimulus
7.6. Satiation
7.7. Exposure
7.8. Associative learning
Repetition and substitution
8.1. Behavioral practice/rehearsal
8.2. Behavior substitution
8.3. Habit formation
8.4. Habit reversal
8.5. Overcorrection
8.6. Generalisation of target behavior
8.7. Graded tasks
Comparison of outcomes
9.1. Credible source
9.2. Pros and cons
9.3. Comparative imagining of future
outcomes
Reward and threat
10.1. Material incentive (behavior)
10.2. Material reward (behavior)
10.3. Non-specific reward
10.4. Social reward
10.5. Social incentive
10.6. Non-specific incentive
10.7. Self-incentive
10.8. Incentive (outcome)
10.9. Self-reward
10.10. Reward (outcome)
10.11. Future punishment
Regulation
11.1. Pharmacological support
11.2. Reduce negative emotions
11.3. Conserving mental resources
11.4. Paradoxical instructions
Antecedents
12.1. Restructuring the physical environment
12.2. Restructuring the social environment
12.3. Avoidance/reducing exposure to cues
for the behavior
12.4. Distraction
12.5. Adding objects to the environment
12.6. Body changes
Identity
13.1. Identification of self as role model
13.2. Framing/reframing
13.3. Incompatible beliefs
13.4. Valued self-identify
13.5. Identity associated with changed
behavior
Schedules consequences
14.1. Behavior cost
14.2. Punishment
14.3. Remove reward
14.4. Reward approximation
14.5. Rewarding completion
14.6. Situation-specific reward
14.7. Reward incompatible behavior
14.8. Reward alternative behavior
14.9. Reduce reward frequency
14.10. Remove punishment
Covert learning
16.1. Imaginary punishment
16.2. Imaginary reward
16.3. Vicarious consequences
Self-belief
15.1. Verbal persuasion about capability
15.2. Mental rehearsal of successful
performance
15.3. Focus on past success
15.4. Self-talk
Shaping knowledge
4.1. Instruction on how to perform the
behavior
4.2. Information about Antecedents
4.3. Re-attribution
4.4. Behavioral experiments
Social Support
3.1. Social support (unspecified)
3.2. Social support (practical)
3.3. Social support (emotional)
BCT Taxonomy v1: 93 techniques in 16 groupings
@DU5TB1N |

45. Example: Behavior, Determinant, BCTs
COM-B FACTOR DESCRIPTION OF BARRIER POTENTIAL BCTS
Psychological Capability:
Memory, Attention, Decision Processes
Easy to forget the behavior, and no natural
reminders are in place.
• Prompts/Cues
• Goal-Setting
• Action Planning
• Review of Behavioral Goals
Physical Capability:
Motor Skills / Coordination
May not have the dexterity or motor functions
required to properly cuff oneself for accurate
reading
• Behavioral Practice/Rehearsal
• Feedback on Behavior
Reflective Motivation:
Consequence Beliefs
Do not believe the benefits of SMBP outweigh
the costs of doing the behavior
• Provide Information on the Consequences
of Behavior
• Salience of Consequences
• Behavioral Experiments
(linking behavior to outcome)
• Pros & Cons
• BioFeedback
Automatic Motivation:
Emotion
Measuring BP is stressful (in anticipation of
results) and can result in avoidance of SMBP
behavior or inaccurate reading
• Social Support (Emotional)
• Reduce Negative Emotions (Stress Reduction)
• Information about Emotional Consequences
TARGET BEHAVIOR: Self-Monitoring Blood Pressure at Home Consistently Every Day
@DU5TB1N |

46. Program Orientation:
Onboarding
Problem solving
Program Orientation:
Onboarding
After Sam downloads Health Mate, he quickly
navigates to the Programs Tab and selects My
HeartLab.
When Sam first enters My HeartLab, he’s greeted with
a few questions that will help hone in on the most
effective initial experiment for him, including his prior
experience managing his hypertension, his personal
goals, and his preferences.
HOW IT WORKS:
Guiding users through graded experiments to help
them identify strategies that work for them.

47. Program Orientation:
Personalized
Recommendations
The questions Sam answers in his quiz feel very
relevant and are easy to answer. Once he finishes, he
receives a recommendation for an experiment that is
clearly based on the information he provided.
Because he was recently prescribed a new medication,
My HeartLab knows that this is probably the easiest
and most effective behavior for him to master. Sam is
motivated to start this experiment by reading the
impact it has had for others and what it entails.
Social Comparison
HOW IT WORKS:
Encouraging medication adherence for those with
medication.

48. Day 1:
Experiment in Progress
Sam is intrigued by the experiment because he could
never understand how his medication impacts his
blood pressure, or why on one day he gets a higher
reading than on another.
As Sam learns more, an easy to read overview helps
him get a better sense of what he can expect from his
experiment. He’s confident that he can undertake the
steps he needs to learn something valuable.
On Day 1, Sam is prompted to take his medication and
track his blood pressure after he wakes up. At any
point during the day, he can open the app to see what
he’s accomplished or what’s next to do.
Behavioral Experiments
Habit Formation
Commitment
Graded Tasks
Action Planning
Instructions on how to
perform the behavior
HOW IT WORKS:
Showing a clear relationship between users’
behaviors and outcomes on blood pressure
over time.

49. Day 3 & 4:
Viewing Progress &
Getting Support
Sam’s daily tasks for this experiment are pretty
simple. He enters if he took his medications and
when, and he measures his BP so he can be confident
about how taking his medications regularly affects his
blood pressure.
If Sam has any trouble during the experiment, he
might receive a proactive outreach from his
HeartCoach offering alternate ways to remember to
take his medication. When Sam chooses to link his
experiment to a habit, he is given an opportunity to
add it to his calendar or set a notification.
Feedback on Outcomes of
Behavior
Self-Monitoring of Behavior
Biofeedback
Salience of Consequences
Prompts/Cues
Problem-Solving
Information about Antecedents
Conserving Mental Resources
HOW IT WORKS:
Long-term, helping users hack their habits and
sustain them over time without reminders &
notifications.

50. Day 5:
Finishing the
Experiment
Success! Sam completed the experiment! My HeartLab
congratulates Sam and awards him a badge for sticking to it.
Even though he missed logging his medication a couple
times, he understands that he can still be confident in the
results. More importantly, Sam can see the insight he’s
gathered along the way. He’s surprised by how much of an
impact linking his medication to his morning routine had, so
he’ll try to keep that habit going. Excited about what he
learned, he shares his results with his brother who also has
hypertension.
Now that Sam has acquired one strategy for managing his
medication routine, he can build on this success and try
others.
Nonspecific Reward
Feedback on Outcome
of Behavior
Salience of Consequences
Biofeedback
HOW IT WORKS:
• Showing a clear relationship between user’s behaviors and
outcomes on blood pressure over time.
• Connecting users to non-digital resources (clinician,
pharmacist).
Rewarding Completion

51. Evaluation: Test, Learn, Adapt
Baseline
Measure the
behavior and
outcomes before
implementing your
intervention.
Engagement Determinants Behavior Outcomes
Measure adoption
and engagement to
understand impact
they have on
outcomes
Measure the COM-B
factors you are
targeting in your
intervention.
Measure behavior to
see if it changes.
Measure the
downstream
outcomes you are
trying to achieve.
e.g., starting
medication adherence
and outcome effects
e.g., intervention
adoption, usage,
content access
e.g., changes in
motivation, capability,
or opportunity targets
e.g., number of days
medication is taken. BP
is measured, etc.
e.g., hypertension as
measured by wireless
cuff.
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52. Discussion + Q&A
Questions?
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53. CALL FOR SPEAKER
PRESENTATIONS
April 6 & 7, 2020
healthexperiencedesign.com
#HXD2020

54. //FIN
Dustin DiTommaso
SVP Behavior Change Design
MAD*POW
dustin@madpow.net | @DU5TB1N