within ImagineCare 3. Results & Takeaways TONIGHT’S TALK Mad*Pow is a design agency that strives to help people improve their health and wellness, meet their financial goals, learn, and connect.
are we trying to achieve? How to achieve it? WHAT IS BEHAVIOR CHANGE DESIGN? System Outcomes & Target Population Behavioral Outcomes for Individuals Performance Objectives for Individuals Behavioral Determinants Design of Product, Messages, Materials, Activities Implementation & Adoption Intervention Functions & Behavior Change Techniques
Improving the US Health Care System Better care Patient satisfaction Clinician satisfaction and minimal burden Better value Reduced need for high-cost care (ER, Inpatient) through management and prevention Correct level of care delivered when care is needed (ER vs Urgent Care vs PCP) Reduced need for medications Better health Reduced mortality Chronic conditions under control, or where possible, in remission Improved quality of life for patients STEP 1: SYSTEM OUTCOMES & TARGET POPULATION
Available evidence about interventions & outcomes Feasibility of interventions – technology, cost, logistics, burden Overlap in conditions and behavioral objectives STEP 1: SYSTEM OUTCOMES & TARGET POPULATION Who can help us achieve those outcomes? ImagineCare chose to focus on people with health conditions that offered the greatest potential impact on the system outcomes, based on:
changes Physical activity Stress & psych health STEP 1: SYSTEM OUTCOMES & TARGET POPULATION Target population & behavior categories ImagineCare’s pilot conditions and related modifiable behaviors
changes Physical activity Stress & psych health STEP 1: SYSTEM OUTCOMES & TARGET POPULATION For sake of example… We’ll use hypertension self monitoring to show how the behavior change design process plays out
impact on system outcomes? What’s the behavior? How often should it occur? Are there any exception cases or special circumstances? Why does the behavior impact outcomes? RESEARCH QUESTIONS • Help doctor and patient determine whether treatments are working • Identify hypertensive crisis in the moment so patient can seek emergency care • Increase patient awareness and engagement with care – halo effect can improve other behaviors WHY? Patients with uncontrolled blood pressure should measure their blood pressure once per day against a goal recommended by their physician, and take appropriate action based on readings. BEHAVIORAL OUTCOME
as part of the behavior? What do they need to do differently to achieve desired change? How should the behavior typically play out, start to finish? Any required resources? Does anyone else need to be involved? Where should it occur? What barriers may exist? How can barriers be addressed? RESEARCH QUESTIONS PERFORMANCE OBJECTIVES FOR MONITOR BP DAILY • Recognize importance of monitoring BP • Set goal for behavior and outcome • Obtain BP cuff & learn to use • Measure BP daily • Compare reading to goal & take appropriate action • If not measuring daily – identify barriers, problem-solve, adjust as needed
CAPABILITY Physical Psychological OPPORTUNITY Physical Social MOTIVATION Reflective Automatic The COM-B Model (Michie, et al) provides a framework for identifying behavioral determinants BEHAVIOR Michie S, van Stralen M M, West R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions, Implementation Science, 2011;6(42). doi: 10.1186/1748-5908-6-42
about what needs to be measured, how and when Knowledge of goal Knowledge of what action is appropriate based on reading STEP 4: BEHAVIORAL DETERMINANTS What factors increase likelihood of success? OPPORTUNITY Physical Social MOTIVATION Reflective Automatic BEHAVIOR Measure BP Daily & Take appropriate action
BP Having resources or tools that will allow action to be taken Social Relationship with a clinician Being able to openly use BP cuff in social environment CAPABILITY Physical Skills to take a BP reading Psychological Knowledge about what needs to be measured, how and when Knowledge of goal Knowledge of what action is appropriate based on reading STEP 4: BEHAVIORAL DETERMINANTS What factors increase likelihood of success? MOTIVATION Reflective Automatic BEHAVIOR Measure BP Daily & Take appropriate action
CAPABILITY Physical Skills to take a BP reading Psychological Knowledge about what needs to be measured, how and when Knowledge of goal Knowledge of what action is appropriate based on reading BEHAVIOR Measure BP Daily & Take appropriate action OPPORTUNITY Physical Having a BP cuff Having time to measure BP Having resources or tools that will allow action to be taken Social Relationship with a clinician Being able to openly use BP cuff in social environment MOTIVATION Reflective Having a goal Having motivation to take action Social support & accountability Automatic Emotional reaction to condition and behavior
Incentivization Coercion Training Restriction Environmental Restructuring Modeling Enablement PRIMARY INTERVENTION FUNCTIONS What are the primary functions of the intervention?
Recognize importance of monitoring BP Set goal for behavior and outcome Obtain BP cuff & learn to use Measure BP daily Compare reading to goal & take appropriate action If not measuring daily – identify barriers, problem-solve, adjust as needed BEHAVIORAL DETERMINANTS Skills to take a BP reading Knowledge about what needs to be measured, how and when Knowledge of goal Knowledge of what action is appropriate based on reading Having a BP cuff Having resources or tools that will allow action to be taken Having a goal Having motivation to take action Having time to measure BP Social support & accountability Emotional reaction to condition and behavior Education Persuasion Incentivization Coercion Training Restriction Environmental Restructuring Modeling Enablement PRIMARY INTERVENTION FUNCTIONS What are the primary functions of the intervention?
Recognize importance of monitoring BP Set goal for behavior and outcome Obtain BP cuff & learn to use Measure BP daily Compare reading to goal & take appropriate action If not measuring daily – identify barriers, problem-solve, adjust as needed BEHAVIORAL DETERMINANTS Skills to take a BP reading Knowledge about what needs to be measured, how and when Knowledge of goal Knowledge of what action is appropriate based on reading Having a BP cuff Having resources or tools that will allow action to be taken Having a goal Having motivation to take action Having time to measure BP Social support & accountability Emotional reaction to condition and behavior Education Persuasion Incentivization Coercion Training Restriction Environmental Restructuring Modeling Enablement PRIMARY INTERVENTION FUNCTIONS What are the primary functions of the intervention?
are best suited to perform these functions, to influence the behavioral determinants and performance objectives? We choose techniques and strategies from a large toolkit of theories and frameworks Self Determination Theory – a theory of motivation concerned with supporting our natural or intrinsic tendencies to behave in effective and healthy ways. Conditions supporting the individual’s experience of autonomy, competence and relatedness are argued to foster the most volitional and high quality forms of motivation and engagement. Social Cognitive Theory – describes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence upon each other. According to SCT, self-efficacy, goals, and outcome expectancies are the three main factors that affect the likelihood that a person will change a health behavior. Behavioral Economics & Game Mechanics – human decisions are strongly influenced by context, including the way in which choices are presented to us.
Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions, Annals of Behavioral Medicine, 2013;46(1): 81-95. doi: 10.1007/s12160-013-9486-6 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 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 behavior 2.3. Self-monitoring of behavior 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 Social Support 3.1. Social support (unspecified) 3.2. Social support (practical) 3.3. Social support (emotional) 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 Shaping Knowledge 4.1. Instruction on how to perform the behavior 4.2. Information about antecedents 4.3. Re-attribution 4.4. Behavioral experiments
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 behavior 2.3. Self-monitoring of behavior 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 Social Support 3.1. Social support (unspecified) 3.2. Social support (practical) 3.3. Social support (emotional) 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 Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions, Annals of Behavioral Medicine, 2013;46(1): 81-95. doi: 10.1007/s12160-013-9486-6
able to measure blood pressure BEHAVIORAL DETERMINANT: • Instructions on how to perform behavior • Verbal persuasion about capabilities • Biofeedback • Social support (practical) SELECTED BEHAVIOR CHANGE TECHNIQUES: Training INTERVENTION FUNCTION:
participate Persuasion, Incentivisation Material Incentive Large risk-bearing entities (ACOs, self-insured employers) invite at- risk populations to participate via email or offline outreach Social Comparison Credible Source During a follow-up visit at your doctor’s office, a staff member talks with you about ImagineCare, a program that will help you monitor your blood pressure daily and encourage and support you in the health changes you want to make. Social Support (Practical) Your college has introduced a new program for wellness and stress management, called ImagineCare. ENROLLMENT DESIGN • From a trusted source • Volitional • Confidential • Quick & simple as possible • Mobile first ACCESS MODEL – B2B2C Information about health consequences
process Persuasion, Education, Environmental Restructuring, Incentivization, Enablement Prompts/cues; Instructions on how to perform behavior Prompts/cues; Feedback on behavior; Discrepancy between current behavior and goal; Social support (practical) Social reward
MATERIALS, ACTIVITIES Environmental Restructuring, Training, Incentivization Prompts/cues Feedback on behavior; Social reward Feedback on behavior Instructions on how to perform behavior Biofeedback Instructions on how to perform behavior
via active and passive sensors Education, Incentivisation, Enabling Goal for the outcome Biofeedback Self-monitoring outcomes Action planning; Prompts/cues; Conserving mental resources Self-monitoring behavior
a care plan Enablement, Education, Incentivisation Goal setting (behavior - measure BP daily) Goal Setting (outcome - achieve prescribed range) Action planning; Commitment; Behavioral contract; Social support (practical); Credible source; Restructuring the social environment
support & triaging Education, Enabling, Incentivization, Persuasion Feedback on outcomes of behavior; Social reward Feedback on outcomes of behavior; Problem solving Social support (emotional); Social support (practical)
reduction in cost of ER care 23% Overall savings per patient per month $255 reduction in poorly controlled high blood pressure 50% satisfaction rating for ImagineCare Health Navigator & RN services 95% the national employer health & wellness program engagement 4x reduction in hospital admissions 56% *Engagement vs. Towers Watson National Survey of employer health and wellness programs “Staying@Work Report 2013/2014, United States”
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