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Behavior Change Design: A Comprehensive Yet Practical Approach to Improving Health Outcomes

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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.

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Behavior Change Design: A Comprehensive Yet Practical Approach to Improving Health Outcomes

  1. 1. Behavior Change Design A Comprehensive Yet Practical Approach to Achieving Health Outcomes Dustin DiTommaso | SVP, Behavior Change Design | @DU5TB1N Nov 2020
  2. 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. @DU5TB1N |
  3. 3. An Opening Proposition @DU5TB1N | 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. 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. @DU5TB1N |
  5. 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 @DU5TB1N |
  6. 6. A Network of Behaviors Who Needs to Do What? ✫ Members / Patients ✫ Providers / Clinicians ✫ Caregivers / Significant Others ✫ Payer Staff ✫ Provider Staff @DU5TB1N |
  7. 7. What Is Typically Done? Provide Information @DU5TB1N | 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. 8. What Is Typically Done? @DU5TB1N | 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. 9. What Is Typically Done? @DU5TB1N | 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. 10. What Is Typically Done? @DU5TB1N | 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. 11. Understand Behaviors in Context PROBLEM SOLUTION @DU5TB1N |
  13. 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. 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 @DU5TB1N |
  15. 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 @DU5TB1N |
  16. 16. Outcome Behavior Actor Behavior Behavior Actor BehaviorActor Behavior Behavior Behavior Behavior Behavior Identify the Population & the Behaviors @DU5TB1N | 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. 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 @DU5TB1N |
  18. 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 @DU5TB1N |
  19. 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? @DU5TB1N |
  20. 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 @DU5TB1N |
  21. 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: @DU5TB1N |
  22. 22. COM-B Model for Understanding Behavior Behavior Michie et al (2011) Implementation Science Behavior occurs as an interaction between three necessary conditions @DU5TB1N |
  23. 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. 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 @DU5TB1N |
  25. 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 @DU5TB1N |
  26. 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 @DU5TB1N |
  27. 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. 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. 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. 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. 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. 32. Education Increasing knowledge or understanding
  33. 33. Training Imparting skills necessary to perform target behaviors
  34. 34. Needs satisfaction Satisfying basic psychological needs of autonomy, competence, and relatedness
  35. 35. Persuasion Using communication to induce positive or negative feelings or stimulate action
  36. 36. Incentivisation Creating an expectation of reward
  37. 37. Coercion Creating an expectation of punishment or cost
  38. 38. Restriction Using rules to reduce the opportunity to engage in the target behavior
  39. 39. Environmental Restructuring Changing the physical or social environment
  40. 40. Modeling Providing an example for people to aspire to or imitate
  41. 41. Enablement Increasing means/reducing barriers to increase capability (beyond education and training) or opportunity (beyond environmental restructuring)
  42. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. @DU5TB1N |
  52. 52. Discussion + Q&A Questions? @DU5TB1N |
  53. 53. CALL FOR SPEAKER PRESENTATIONS April 6 & 7, 2020 healthexperiencedesign.com #HXD2020
  54. 54. //FIN Dustin DiTommaso SVP Behavior Change Design MAD*POW dustin@madpow.net | @DU5TB1N