Disruption of the 'Usual' - Rethinking Behavior

Change and Communication in Nutrition

Education

R. Craig Lefebvre, PhDchief maven, socialShift

Lead Change Designer, RTI InternationalResearch Professor, Florida Prevention Research

Center at the University of South Florida College of Public Health

Theory: The Frames We Use to Understand and Solve Problems

The Power of Theory• Explains how or why things are related• Guides us to identify what’s important• Suggests what questions to ask• Creates assumptions about what we

should do about the problem• Proposes what objectives to set• Determines how we measure success

Changing Scales of Reality

• The Frame Problem – It is impossible to know all the potentially relevant facts and determinants of a puzzle, given the overwhelming number of possibilities and combinations of variables.

• The Micro-Macro Problem – Our desire to achieve macro outcomes, ones that involve changes among large numbers of people, or in society as a whole, are driven by the micro actions of individuals; changes at different levels of organization are emergent, not simply an adding up of the components.

“Social change programs need to consider more than one scale of reality at a time.”

Micro-Macro Gap

X 85 bn

≠

Sources of Program Failure

• Insufficient intervention resources• Nonsupportive social and political

environment• Measurement and evaluation

design• Wrong theory used to understand

problem and develop strategies

Where Theory Can Make a Difference

• What problem to tackle - and how

• What the program objectives should be

• Which priority audiences to choose, and how to characterize them

• What questions to ask in formative research

• Which approaches may be the best to use with specific groups of people

• How to best promote behaviors, messages, products, and services

Theories of ChangeStages of Change

Health Belief Model

Social-Cognitive Theory

Diffusion of Innovations

Social Networks

Precontemplation

Susceptibility

Reciprocal determinism

Relative advantage

Opinion leaders

Contemplation Severity Behavioral capability

Compatibility Groups

Preparation Threat Expectations Complexity Adding or removing members

Action Perceived benefits

Self-efficacy Trialability Bridging groups

Maintenance Perceived barriers

Observational learning

Observability Rewiring groups

Decision balance

Cues to action

Reinforcement Network weaving

The Rational Person

The New Model

The New Model

RationalDeliberateForward lookingGets loss in analysisEmotional

InstinctiveImmediate needsLazy

Behavioral Economics

The study of the allocation of psychological (mental) resources to decision-making and

behavioral choices.

Personal Biases• Loss Aversion - People are more averse to losing things than they are

inclined to gaining things.

• Status Quo Bias - One of the best predictors of our future behavior is our current behavior. This is because inertia is so powerful.

• The Dual Self - People have competing preferences, with different preferences dictating different actions at different times.

• Attention Constraints - People get distracted. Simply paying attention to one’s goals is often half the battle in reaching them.

• Defaults - People make passive choices based on how the choices are presented to them.

• Resource Slack - In planning for the future, people realistically assumed that money will be tight, but they expect free time to magically materialize.

Scarcity is the fundamental economic problem of having seemingly unlimited human wants and needs in a world of limited resources.

Scarcity

Bandwidth

Tunneling

Bandwidth

Limited Resources

• Scarcity of cognitive capacity –• Cognitive resources available to people at any

moment are limited and can be depleted by being used for other activities. So increasing the cognitive demands of nutrition programs may in fact be making them less likely to succeed.

• Rules-of-thumb; simplify Choices.

Limited Resources

• Scarcity of self-control –• Think of self-control as a psychic “commodity”

of which we have a limited stock, so that using some up for one task (“continuing to exercise when you want to stop”) depletes the amount available for other tasks (“resisting the extra cookie after your workout”).

• Defaults; Time Management skills; explicit Commitments

Scarcity

Bandwidth

Tunneling

Tunneling

Limited Resources

• Scarcity of attention –• Think of attention as another precious

commodity – people do not have unlimited attention and may not pay attention to the ‘right’ things – they are busy paying attention to others.

• Prompts and reminders; Incentives.

Scarcity

Bandwidth

Tunneling

Multi-Tasking

Limited Resources

• Scarcity of understanding –• People’s mental models of how the world

works (or what makes a food ‘healthy’) may be incomplete; not all underlying causal relationships are correctly or accurately understood.

• Tailoring of messages to existing mental models.

Scarcity & Bandwidth

Understanding Attention Self-control Cognitive

capacity

Framing Effects, Social Comparisons, Norms

• Link reminders to a specific goal they have set.

• People are more responsive to what they will lose than what they will gain by (not) doing something.

• Compare what people do with their peers.• Most individuals make efforts to conform to

what they perceive the social norm to be.

Behavioral Economics: So What?

Stop berating people for not being responsible and start to think of ways instead of providing the poor with the luxury that we all have, which is that a lot of decisions are taken for us. If we do nothing, we are on the right track. For most of the poor, if they do nothing, they are on the wrong track.

– Esther Duflo

“

”

Diffusion on New Ideas and Behaviors

Characteristics of SegmentsInnovators Early

AdoptersEarly Majority

Late Majority

Laggards

Venturesome Respect Deliberate Skeptical TraditionalHigh tolerance of risk

Opinion leaders

Very local perspective

Sensitive to peer pressure and norms

The traditionalists – tried and true

Fascinated with novelty

Well-connected socially and locally

Very engaged in peer networks

Cautious Keepers of the wisdom

Willingness to travel to learn

Resources and risk tolerance to try new things

Rely on personal familiarity before adoption

Usually scarce resources

Near isolates in their social networks

Seen as mavericks, not opinion leaders

Self-conscious experimenters

How does this help me?

Minimize uncertainty of outcomes

Suspicious of innovation and change agents

Social networks transcend geographic boundaries

They are watched by others – and they know it

Want to see the proof locally

Adoption will not fail

Attributes of Innovations

• How is this better than what I currently do?      

• How is it relevant to the way I go about my everyday life?      

• Is it simple enough for me to do?   • Can I try it first?    • Can I watch others and see what

happens to them when they do it?

The Innovation Chasm

Source: Moore, G.A. Crossing The Chasm. Capstone Publishing, 1998.

Creating Webs for Change

Social Networks Frame the Opportunities and Constraints for

Change

Social Networks

Opinion leadersGroups

Adding or removing membersBridging groupsRewiring groupsNetwork weaving

Social Networks and Obesity

Adolescent Obesity and Social Networks

• Intervene with the family system, rather than with the individual.

• Tailor family-based interventions to the structure of the family.

• Design support mechanisms for parents and adult family members on the basis of their social ties within the community.

• Use peer networks to encourage increased physical activity.

Source: Koehly LM, Loscalzo A. (2009). Adolescent obesity and social networks. Preventing Chronic Disease; 6(3):A99

New Technologies Expand The Scope and Capacity for Learning

Social Marketing

Designing products, services and behaviors that fit people’s

reality Eating Well on $4.30 a DayOur columnist lives for six weeks as if he is on the Supplemental Nutrition Assistance Program, and learns something he didn't expect.

Brett Arends, The Wall Street Journal 14 December 2013

Eating reasonably well on $4.30 a day turned out to be a bit like a Rubik's Cube puzzle: It seemed impossible until I worked out the trick. Then it became surprisingly manageable, if monotonous.

Positioning Behavior Change

What relevant behavior can we ask people to engage in rather than the one they are currently doing?

How can we make this behavior more compelling, relevant, and potentially more valuable to people when they practice it, in comparison to the alternatives?

Brett’s Tricks• I didn't eat out.

• I didn't eat any packaged or processed foods.

• I didn't try to live on energy bars.

• I avoided cheap carbohydrates, like white bread and noodles.

• I abandoned buying coffee out. For my caffeine needs I carried tea bags instead

Costs of Change

• Financial

• Energy

• Geographical distance

• Opportunity

• Social

• Psychological

• Physical

• Structural

Brett’s Costs• Peanuts and peanut butter

(which cost around $2.50 a pound).

• Eggs (20 cents each).

• Pulses or legumes, like split peas and lentils, which can cost not much more than $1 a pound.

• I rarely ate meats or fish. They were too expensive.

• Milk is expensive, but I had a cup—about 25 cents—a day.

• Healthy carbohydrates: oatmeal, whole-wheat pasta, brown rice, baked potatoes and sweet potatoes, and whole-wheat bread - which I made at home and cost a little more than $1 for a 1½-pound loaf.

• I ate plenty of bananas (sometimes just 20 cents each), and I bought frozen peas, corn and other mixed vegetables for around $1.30 a pound.

• I took a cheap multivitamin a day.

Creating equitable opportunities and access

Where can we locate a service, distribute a product, or create opportunities for members of our priority group to engage in healthier behaviors?

Where Did Brett Go?• I took the subway to

the bigger supermarkets.

• And I hunted aggressively for deals.

• What's on sale is what's on the menu. I found the food aisles at downtown drugstores sometimes had surprisingly good deals.

Communicating change in linguistically, culturally relevant and

ubiquitous ways

How Effective are Health Communication Campaigns?

5%

5%5%

5%

Brett’s Message

My experience has changed how I eat. I am amazed at how cheaply one can eat well—and mortified at how much I have spent needlessly over the years. I suspect I am not alone.

Keys to increasing healthy eating using social marketing

Social marketingbenchmark criteria

Keys to increasing healthy eating using social marketing

Behavioral objective Evaluate healthy eating using multiple behaviorsTackle single behaviors serially over time

Audience segmentation Identify different groupsServe each group with a unique solution

Formative research Conduct formative researchResearch must be consumer oriented

Exchange Offer salient benefits – short-term benefits can be more salient than long-term benefitsConsider trials, rewards and prizes to stimulate trial and repeated behavior

Marketing mix Move beyond communication – interventions must be multifaceted (e.g. more than promotion and communication)Efforts need to be directed at initiating new behavior and encouraging repeat behavior

Competition Undertake competitive analysisKnow your direct and indirect competition

Source: Carins JE, Rundle-Thiele SR. (2013). Eating for the better: A social marketing review (2000-2012). Public Health Nutrition; 28:1-12.

Lessons• Theories should be tools – not straight

jackets• Theories can inform – and blind (the “frame

problem”)• The one with the biggest toolbox wins• It’s a complex world (the micro-macro

gap).• “There’s nothing so practical as a good

theory”

Resources• Lefebvre, R.C. & Bornkessel, A. (2013). Digital

social networks and health. Circulation; 127:1829-1836.

• Mullainathan, S. & Shafir, E. (2013). Scarcity: Why having too little means so much. New York: Times Books.

• Snyder, L. (2007). Health communication campaigns and their impact on behavior. Journal of Nutrition Education and Behavior; 39(Suppl.):S32–S40.

• Valente, T.W. (2013). Network interventions. Science;337:49–53.

• Wakefield, M. A., Loken, B., & Hornik, R. (2010). Use of mass media campaigns to change health behaviour. Lancet; 376:1261–1271.