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5 Behavior Models in Employee Wellness - Transcript

I want to thank everyone for attending this Webinar sponsored by Extracon. My name is Jesse Hercules, and I have been a member of the Extracon team since the beginning in the mid-2000's. For more than 5 years, we've worked with employers and health plans to add engagement to their wellness programs using the latest in online, social and mobile technology as well as the latest science and behavior models. Our goal for today is to give a concise, commonsense overview of the most influential behavior models that we use in health promotion. We'll use concrete examples to show how these models have led to many of the practices we all use in our wellness programs. And we'll talk about the limits of each model. There is no one model that completely explains health behavior, and we have to know the limits of each model that we're using.

And we'll share a few examples from our extensive work with customers like the ones shown here. Our online, social and mobile platform has been proven at employers large and small across the USA for more than 5 years. Our client list includes Fortune 500 companies, major hospitals, and health insurance plans. Much of what we've learned about behavior change in the real world has come from working with customers like MARS, Costco, University of Phoenix, Indiana University Health, and many more. If you'd like to learn more about our COMPLETE WELLNESS PLATFORM, please visit But we've got a lot of ground to cover with the 5 Behavior Models in wellness, so let's get started.

The First model we're going to examine is the health belief model. This was developed in the 1950's when scientists were first learning about the effect of daily behaviors on health - such as the connection between smoking and lung cancer. The Health Belief model predicts whether a person is likely to change their habits in order to affect their health. The prediction is based on the information and beliefs about health that the person has. The person is essentially taking the information and beliefs they have and asking the question, Should I change?

Here's how it works. First, the person looks at how the big the risk is - how likely am I to get the disease, and how serious is it if I do get it? So a person might look at how likely they are to develop type 2 diabetes based on their habits today, and how serious it is if they develop the diabetes. That's the threat assessment. Second, the person looks at the cost/benefit to changing their habits. So they look at the benefits to making a change, and the barriers or costs that would get in the way of making a change. Based on the threat assessment and the cost/benefit, the person decides whether to make a change. So how do we use this model in health promotion? Well, this is the model underlying most of our Health Education efforts. This model says that if we give people the right information, then they will make the best decision for their health. It's all about education. If they know the facts, they will change. And I think we've all said that at times, right. If they only knew! And many times education is exactly what is needed. For example, at Extracon we do a Sleep Health program, and there is a lot that typical adults don't know about sleep. So they often think caffeine is done and out of your system in a couple of hours. Actually, it stays around for 8 hours or more. So if they are having a cup of coffee at 4pm, that could be keeping you awake at 11pm when you're trying to sleep! In some areas like sleep and stress, people really don't know the basic facts yet. Health education is important because your participants have to know what the healthy choice is before they can make the healthy choice.

This model has limits, of course. And here's a great example. These warnings have been on cigarette packs since 1966. That's every pack of cigarettes for 46 years! Every smoker knows this information. And it's not just smoking. If you survey your population you will probably find out they know the basic facts about exercise, eating fruits & veggies, and maintaining a healthy weight. (Click) Education is necessary but it's not the whole story. We also have to do more, if we want to spark real behavior change. So let's move on to model #2.

The next model we will explore is the Social Cognitive model from Dr. Albert Bandura. It's closely related to the Social Learning model, and both are from the 1970's. So you remember the Health Belief model where the person is essentially asking, “Should I change?”. That's not what we're doing with the Social Cognitive model. (animate cross out) Under the Social Cognitive model, your participants are asking themselves a very different question. They are asking themselves, What do people like me tend to do? Do they smoke? Do they exercise? Do people like me order a vegetarian meal, or do people like me go for the biggest steak on the menu? That's the social cognitive model. What do people like me tend to do.

And we use this all the time in health promotion. Let's look an example. This is a brochure put out by city of Louisville. The message is clear from the headline: “Real Men” take care of their health. And you can see some pictures here, showing what kind of real men take care of their health. So if I'm in the target demographic for this brochure, I am going to see the picture of men like myself, and maybe this starts to change my views on what people like ME are doing for their health. I've even seen online wellness programs where they ask you about your demographic information, and then all the faces you see afterward are from your exact demographic. This approach has been studied extensively by Dr. Vic Strecher and others, and it works. Let's take another example. This is a web page put out by a wellness program in California. You can see from the title that it's a collection of participant success stories. The Social Cognitive model is also the reason that success stories are so very important and effective. Success stories change people's views about what people like themselves are doing for health. If I see other people like myself changing their habits and achieving better health - that changes my answer to the question… what do people like me tend to do about health?

So we can leverage the social cognitive model to tailor our communications pieces. But that shouldn't be the only way we leverage the social cognitive model. My challenge for you in the audience is not to stop there, but to think about more ways to add group, team and social elements into your wellness program. If you really want people to believe that others like themselves are making positive changes for health, then find ways for them to make those changes together with their co-workers, peers and family members. Group, team and social wellness programs can really drive behavior change under the social cognitive model.

Now let's talk about the Stages of Change model. This is probably the most widely cited behavior model in our field. This was developed by Dr. James Prochaska and his team in the 1970's. It says that people progress through five stages as they make a health behavior change. The stages are shown on the graph. So let's go through the stages briefly. I'm going to return to smoking cessation as an example. The first stage is called pre-contemplation. That means they are not even THINKING of making a change. So that's the person is not even thinking about quitting smoking, starting exercising, or making some other change. Then in the second stage, they are thinking about it, but no decisions have been made. They are weighing the options. That is contemplation. In the third stage, they have decided to make a change and are in the preparation stage. So this might be someone who has set a quit date for smoking. Or someone who has set a date to start walking, or eating healthy. They are usually trying to arrange their life to make room for this change. In the fourth stage, Action, they have started practicing the new habit. So they have quit smoking, started walking, or what have you. In the last stage, Maintenance, they have been practicing the new habit for several months and now it's become their new normal. So what's the point of this model? The key insight is that we should work with our participants DIFFERENTLY when they are in different stages. Different things work at different stages. A message that's perfectly tailored for someone in the action stage is not helpful at all to someone in the contemplation stage. So here's an example. When someone is in the contemplation stage, we often talk with them about the pros and cons of making a change. They have not made a decision yet, so this is helpful. But once they are in the preparation stage, now it's about removing the barriers to getting started. Pros and cons don't matter since the decision has been made. Dr. Prochaska has focused on having different communication pieces for people in different stages. So there is literally a different book or brochure you hand people based on what stage they are in. And the research shows that tailoring your communications in this way is more effective than using one-size-fits-all communications.

But one main criticism of the model is that it shows behavior change as being linear. Participants go through the stages, in order, and then they are done. Stages of Change doesn't say much about the circular pattern that we've all seen in our participants. We observe a lot of people who are in a cycle of trying hard to live healthy, then life happens and they drop out. Then the recommit and try again, and next year it begins again. We see this in yo-yo dieters, in people trying to exercise, and in many other types of behavior change. And that's when we start to realize that we can't talk about exercise, nutrition, and other daily behaviors as a one-time change. If it were a one-time decision to become a regular exerciser, our participants wouldn't be able to go through this cycle. If it were a one-time decision to quit smoking, there would be no such thing as relapse. So we need models that tells us more about how we build daily habits and what determines success or failure in the long term.

So let's take a look now at the Behavior Grid model being used at Stanford University by Dr. BJ Fogg. This model differentiates between short term, middle term, and long-term commitments. Dr. Fogg classified amount of commitment we are trying to make into three types: Dot, Span and Path. A Dot behavior is a behavior that you are going to do once - where there is only one decision to make. We're pretty good at these. If you look at the kinds of programs where we have a 75 or 80% participation rate, they are like this. Then there are span behaviors. These are things you do for a pre-defined span of time. Like an 8 week weight loss program or a 30-day walking program. These are not designed to last forever, in fact that's a feature. It is easier for participants to commit to and succeed in a span-type program than for them to tackle a new behavior “From now On'”. In the health promotion world we have been pretty successful with this type of program, but it's often been dismissed because the program ends at some point. I would submit to you that this model shows there is a place for these programs in our repertoire of program components, and that SPAN programs can often fill the gap between trying something once and doing it for the rest of your life. Then there are PATH behaviors. PATH behaviors are ones that we intend to undertake from now on. It's a much higher level of commitment, and it's the type of change we have been least successful at in health promotion. This is becoming a regular exerciser, or an ex-smoker, or a vegetarian.

The behavior grid is not just about the length of time you intend to do the new behavior. It also maps out some different types of behavior change. For example, One type is asking people to try something new. Another is asking people to do a familiar behavior. Another is asking people to increase how often they do a behavior. And for behaviors we're trying to cut down on - like smoking - we can ask participants to decrease the behavior or to stop completely.

Now we can see how it all goes together in the Behavior grid. You can see the dot, span and path timelines on the left. You can see the different colors on the top - the types of behavior change. Right now, this probably looks complex to you, and so I'm going to simplify it with an example. Let's say we have a wellness participant named Barbara. She has never had an exercise habit, and she wants to improve on that along with her wellness program manager. But how do we get from point A to point B? How do we get Barbara from where she is to where she has that daily habit of exercise forever? Let's see how we might move through the grid. First, we can take away the part of the grid that deals with reducing or stopping a behavior. In this case we're trying to build a new behavior. So we're left with nine squares. Now, exercise is an unfamiliar behavior for Barbara, so that means it's in the green column. So imagine you're working with Barbara. I don't think it's really smart to ask Barbara to commit to a daily exercise habit from now on. If we tell her that she has to go from Zero to a permanent habit, we're not likely to succeed. So let's put an X in that box. And let's not even ask Barbara to commit to a week or a month of exercise. We can put an X in that box as well. What we want to do is ask Barbara to take a 10-minute walk, one time. And then we'll talk to her tomorrow and find out how it went. So we are in the Green Dot area. Try something new, and just try it once. Easy, right? OK, so Barbara takes a 10 minute walk and sees that it's pretty easy to do. Now where do we go? Again, I don't think we ask her to do the 10 minute walk every day from now on. That's still too big of a commitment. Let's ask Barbara to take the same 10 minute walk every day this week. And then we will talk with her again. So that's a Blue Span. It's Blue because the 10 minute walk is now a familiar behavior. And it's a SPAN since we agreed it was only a one week commitment. So now we meet with Barbara again and find out she's been able to do the 10 minute walk every day for a week. Now, we ask her to do the same thing next week, but for 20 minutes each day. And then the next week for 30 minutes each day. Those are Purple Span strategies. We are increasing that familiar 10 minute walk up to 30 minutes. But she is still only committing for one week and then we follow up. Finally, we are ready to start talking about how to make this a long-term commitment. Now the next time we talk to Barbara we talk about how to go from a one-week or one-month commitment into something she can do from now on. I believe that many of the problems we have in wellness are from trying to take people directly into those boxes marked with an X. We want the new behavior to be permanent, full-intensity, and instant. The message of this model is that we have to start with trying something, then commit to a few days or weeks, and then we can start talking about a permanent commitment. But how we do make the permanent commitment work? It's not just one decision. Now we need a model for how a behavior gets repeated day after day and week after week.

So now we're ready to talk about the 5th and final model for today. It's also from Dr. Fogg at Stanford. It's the model that explains how to make those PATH changes that are sustainable for the long term. So let's continue with the example of Barbara and her physical activity. We want her to keep exercising 30 minutes a day * five days a week. So that's five decisions a week times 52 weeks a year. That's 260 times a year. How do we make that happen? The key insight here is that for every one of those 260 times a year, we have to bring together three things - motivation, ability, and a trigger. So we have to have some motivation to exercise - perhaps because she knows it's good for health. Perhaps because it will help her earn the annual wellness incentive. Perhaps because it's something she does with her co-workers and has become part of her social life. There are many potential sources of motivation, and we should supply several of them so as to reach more participants. The behavior has to be reasonably easy to do - for example walking 30 minutes rather than running a marathon. That's why in our programs at Extracon we focus on helping participants meet health guidelines such as 150 minutes per week of exercise or 5 a day for fruits and veggies. These are goals within almost everyone's reach and you don't have to outcompete the other person to reach the goal. And finally, the most important part. Each and every time we want them to do the behavior there has to be a trigger. There has to be something that triggers them to take their daily walk right now, and not later. This can be a social trigger if they do the behavior with others, a competitive trigger if they are helping a team to reach a milestone, or a technology-enabled trigger that reminds them if they haven't logged progress lately. A good wellness program has many sources of triggers, just as it taps into many sources of motivation. That is the way to reach the most participants. So in the final analysis, if we want to help Barbara to reach her health goal with physical activity, we need to run programs all year long that supply various kinds of motivation and triggers for healthy behaviors. We think our Extracon programs are one way to do this, but you can probably find other ways to meet these goals as well.

Now that we're drawing to a close, let me summarize what we've learned today. First we talked about the Health Belief Model. This was the health education model - it says that if people have the right information, then they will change their health habits. I think we can all agree that health education is important. Participants have to know what the healthy choice is before they can make it. But we also know education alone is not enough for behavior change. Second, we talked about the Social Cognitive model. When people are making choices, oftentimes they are not asking themselves “what should I do”…. Instead they are usually asking themselves “what do people like me tend to do”. Do people like me tend to smoke, or not? Do people like me eat healthy foods, or not? We also talked about the need to use group, team and social programming to change those perceptions and show people that their peers are working towards health. Third, we talked about the Stages of Change model, in which participants move through five stages on their way to behavior change. We talked about the success of this model in helping us tailor our communications based on the stage participants are in, but we also talked about the limitations of this model in addressing the issue of relapse. The fourth model we examined was the Behavior Grid model from Dr. BJ Fogg at Stanford. This model separates the time commitment into three types. Dot behaviors are done once, Span behaviors are done for set time period, and Path behaviors are done from now on. I argued that we need to start with introducing new health habits to participants in small doses - asking them to try a new healthy habit just once or twice. Then we can step them up to a span program - like a 30 day walking program or an 8 week stress program. Then we're in a position to talk about permanent, PATH type changes. When we jump straight to PATH approaches without a SPAN program, we run the risk of getting into the relapse cycle. The fifth model we examined was BJ Fogg's behavior model. This model shows what is needed to sustain longterm behavior change. It shows that persistent behaviors are not the result of one big decision or one big epiphany. Instead, sustainable behaviors are about having three elements in place every day: motivation, ability AND a trigger. So we have to have some reason to make the healthy choice, and it has to be reasonably easy to do, and we need to build in triggers into our daily lives to prompt us to make that healthy choice.

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