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Got Engagement? - Transcript

Welcome! My name is Jesse Hercules and I'm one of the founding team, so I'm in a good position to introduce Extracon and our story before we get to today's main topic of building engagement in health. In 2007 we gathered a group of health experts, computer programmers and investors and launched Extracon with a mission to make worksite wellness programs that were truly engaging for the whole population. Since then, we've grown into a complete wellness platform for employees and health plan members, including a Health Risk Assessment, Personal Action Plan, Individual Programs, Team Challenge Programs, and Incentive Dashboards. Our goal at Extracon is to give you a simple and complete platform to run your wellness program. You can visit our newly redesigned site at extracon.com to learn more.

We've been lucky enough to work with a lot of great customers who are at the forefront of engaging their employees in health. Customers like Costco, Red Bull, MARS, Highmark Blue Cross, University of Phoenix, City National Bank and others have used our tools and concepts to get their employees engaged. But what does that mean, and how do you measure it? Let's start today's talk with a simple but fundamental question. - What is engagement? (Move to next slide)

There's an important reason why I ask this question. We have to agree on what engagement is before we can measure it and improve it. So when people ask me how to build engagement, I ask them to be more specific - what does engagement mean to you? They usually respond like this…. What is Engagement? Well… I know it when I see it! And I think we all have that intuitive sense of what a wellness program with great engagement looks like. I've had the privilege of working with a lot of wellness programs, and you can spot which programs have engagement and which ones don't. But I'm a data-oriented person so I can't be satisfied with a definition like this. So then we ask the employers, what's your engagement rate today and how do you measure it?

And they usually tell us one of three things - I call these the three myths of measuring engagement. Myth #1: Clients will tell us how many people are using online learning modules, or attend the lunch & learn programs, or attend onsite classes with a health educator. Now everyone knows that health education is important. People have to know WHAT the healthy choice is. But here's the problem. Some of your health education participants will make big changes to their lifestyle. But some won't, and our engagement metric has to show the difference between education and engagement. Myth #2: We ask clients how they measure engagement, and they tell us how many people completed at least 2 calls with a health coach. Now I think health coaching can be very useful, and that talking with a coach is often the best way to help a participant remove those self-imposed roadblocks and start making progress toward health. But here's the problem. Some of these participants make big strides toward health by adopting new daily habits - but some participants just do 2 phone calls and never change a thing. Our metric has to spot the difference between talk and action! Myth #3: We ask clients how they measure engagement, and they tell us how many people earned the annual incentive. Whether this is a good metric or not depends on what you are incent-ing. But here's the problem. Some of the participants who earn an annual incentive are becoming engaged in their health all year long. But some participants are just completing a few annual requirements, then disappearing for most of the year. Our engagement metric has to differentiate those who are engaged all year round and those who aren't.

So here's the metric that I use in working with wellness programs to build engagement. One unit of engagement is when a person takes a measurable action to improve health. Here's the visual - imagine a wellness program participant who takes dozens of measurable actions every month to improve health. It could be having an apple instead of a candy bar. It could be parking in the far corner of the parking lot to make themselves walk a few more steps. It could be taking 15 minutes in the evening to meditate. We think these small but measurable daily actions are the core of engagement. Our goal in building engagement is to have participants doing as many of these things as possible every day, every week, every month and every year. If your participants are taking lots of measureable actions to improve health, you have a program with great engagement. It's as simple as that. We think this definition fits what wellness leaders are talking about when they say “we know engagement when we see it”. But now we've turned it into something that we can measure and improve. I absolutely believe you should including the once-a-year items in this list. Such as your flu shot. Such as completing a biometric screening. Such as a quarterly check-in with your coach. But I also believe in aiming for 50 or 100 or 365 units of engagement every year. And if that's your target you'll find that the bulk of the engagement has to come from daily habits around exercise, nutrition, managing stress, and getting quality sleep. So now that we have a definition for engagement, let's look at how it fits into the larger picture of health costs and healthcare in America.

So now that we know what Engagement is, and how to measure it…. Why does it matter? It matters because engagement is the driving force behind our health costs and our quality of health. That's right - our quality of health depends on our health behaviors just as much as it depends on the money we spend. And here's one way to visualize it. The World Health Organization ranked countries by health expenditure as well as by the actual health their citizens enjoy. We are #1 in expenditures but only #38 in the quality of health we enjoy. Why do we spend so much and yet have such poor health to show for it? Health care experts indicate that both high costs and poor health are driven by lifestyles like physical activity, diet, weight and smoking. Changing our lifestyles can affect up to 70% of the current health care expenditures. Not to mention our functional health, reduce sick days at work, and improve productivity. So it's the daily small actions to improve health that matter in the end. That's the same thing we're measuring with our engagement metric. If our participants are taking measurable actions every day for their health, they are absolutely making lifestyle changes like these. Now it's time to take these concepts and map them onto our employee wellness programs that each of you are running every day.

In our field we have a wide array of wellness programs aimed at many aspects of health. You can see on this slide different aspects of your wellness program arranged according to the number of units of engagement required for success. A health assessment or onsite screening is really just one unit of engagement - and you're done until next year. Telephonic coaching might be four phone calls per year. Put physical activity requires 150 or more units of engagement per year. And when we get to nutrition and weight loss we're talking about over 1,000 mealtimes each year where participants have to make a choice to eat a healthy meal. If you look at most wellness programs, they are very successful at things on the right side of the scale - things that require fewer units of engagement. And we're less and less successful as we move to the left side of the scale and try to do things that require more engagement. Why have we been so successful at things that take a few units of engagement, and so unsuccessful at things that take many units of engagement?

For the most part, this is because we've been very reliant on monetary incentives. I know of many wellness programs that are paying $300 or more in incentives for employees to complete an HRA and a biometric screening. And that works pretty well. Even if you're buying half a dozen units of engagement - such as an HRA, a biometric screening, and two calls with a health coach…. Your $300 or $500 incentive is going to work well. But what happens when you need to buy 100 units of engagement for a year's worth of physical activity? Or 1000 units of engagement for healthy mealtime choices? All of a sudden your $300 isn't going to work. You're only allocating few pennies per healthy meal or per workout, which isn't going to work as a motivator. Now we have to tap into different sources of motivation. And believe it or not, there are lots of NON-financial sources of motivation.

The best place to look for these additional sources of motivation is to look at the longstanding models in psychology, such as Maslow's Hierarchy of Needs. Here, I've put Maslow's hierarchy on the Y axis. Many of you may remember this model from college or professional training. Let's start at the bottom with basic needs and work our way up. Money or financial incentives are relatively low on the hierarchy - down at the level of basic needs. That's why they run out of steam when we try to use them to change daily behaviors. Now let's move up to Psychological and social needs. These include friendship, self-esteem, family connectedness, confidence, achievement, and respect by others. Those are psychological and social needs. I typically think of this as being positive peer pressure to help establish healthy habits as a community norm. And even higher on the scale are what Maslow called self-fulfillment needs. This means our need and motivation to be the people we want to be. In other words, if you believed that taking care of your health was part of being a good parent or caregiver, if taking care of your health is part of being a responsible member of your community, if taking care of your health was part of being the kind of person you want to be - - then it becomes a very strong motivator.

As we just saw, we can't depend on financial incentives alone to provide the motivation. We have to tap into intrinsic motivations that are further up the hierarchy of needs. In other words, our program design has to tap into our needs for accomplishment, social connectedness, respect of others, and becoming the person we want to be. And that's not as easy as just writing a check. If you think about those specific motivators you can come up with program design elements. For example, you can't meet participants' social needs if your program is purely individual. You need programs that participants can do together in groups or teams. If your program wants to tap into the need for the respect of others, it needs to allow participants to share information about their progress with others. If you and I can see each other's progress toward the program goals, we can cheer each other on and hold each other accountable. If your program wants to taps into our need to connect with our families, you need to include spouses and dependent children in the program - which means it has to be accessible from offsite. If you want to tap into people's need for achievement, your program needs to set clear goals and give participants feedback on their progress to the goals. Your program also needs to be difficult enough that participants feel a sense of accomplishment when they achieve the goal. If you want a program that taps into our needs to become the people we want to be it has to give them opportunities to set a good example and be a leader among their peers. So those are some ways we can add more tools to our motivation toolkit and move up the hierarchy of needs to accomplish the harder objectives of changing lifestyle.

So now that we've looked at the big picture, I want to bring us back the definition of engagement we started with. If we want people to take daily actions for their health, what is going to trigger each of those daily actions? To explain these triggers, let's turn to a new model and very successful model developed at Stanford University.

What is going to trigger the person to take that health positive action each day? This model is about triggers and showing when they succeed and when they fail. Dr. BJ Fogg's Behavior Model, as seen here, gives us the answer to that question. This model is rapidly becoming influential in health behaviors and in many other places. I believe that in 5 or 10 years you will see this model cited even more often than Stages of Change or other models from the 1970's that predominate our thinking today. http://www.behaviormodel.org/ What this model says, is that for every unit of engagement we have to bring together motivation, ability, and a trigger. That's the equation at the top - behavior = motivation, ability and a trigger. You can see it takes both motivation and ability into account - how hard is the task, and how motivated is the person. Triggers succeed or fail based on how hard the task is and how motivated the person is. That's the orange line in the middle. So we're going to take two examples. One where the trigger works, and the second example where the trigger fails. First let's talk about an example where the trigger works. Let's say the employee has a high motivation to get their flu shot. Also, the employer has made it easy to get your flu shot by offering it onsite. So we have high motivation and the task is easy to do. Then the employee walks into work and sees a poster saying flu shots are available today in the onsite clinic. That's the trigger and the employee goes to get the flu shot. We've brought together motivation, ability, and a trigger and got one unit of engagement. Let's take another example. Let's say I'm a typical employee with a low level of exercise motivation. My employer is recruiting a team to run a marathon, so the difficulty level is very high. With low motivation and high difficulty, we're on the wrong side of the orange line. You can see the text: Triggers fail here. It doesn't matter how many posters you put up or how many emails you send. I'm not going to jump off the couch and run 26.2 miles today. So this model tells us how to trigger each unit of engagement. We have to bring together motivation, ability and a trigger each time we want participants to take a positive action for their health.

Now let's talk about how to design more and better triggers into our programs. Your program needs to actually trigger those daily actions. How can we provide triggers for daily engagement? Here are 4 ideas. First, make sure each program communication you send is formatted as a trigger. Every communication piece needs a clear call to action and a clear next step for participants to take. Second build more triggers by using email, text messaging and social media. It will make your life a lot easier if your wellness platform can send the emails to the right participants at the right time automatically. Text messages have an even higher read rate than email, and reach people wherever they are - not just when they are at the desk. Wellness Blogs, twitter feeds, and wellness Facebook pages can all be used effectively to put triggers in front of participants. Third, teach participants to set up their own Triggers. Imagine if you've educated your participants on the importance of triggers, and then allow them to set up a few emails or text messages that are automatically sent from the wellness platform. Or, even without using technology you can educate participants about setting up triggers at home. For example, leaving their exercise clothes out so they are the first thing the participant sees when they wake up in the morning. Let participants set up their own triggers. Fourth, give participants the ability to trigger each other. So I should have the ability to invite you to join a wellness program or event with me. Your wellness platform should let participants invite friends to go walking over lunch, or to post a healthy recipe in a way that gets sent to my teammates, or to share progress with a few friends so we can hold each other accountable to our goals. Give participants the ability to trigger each other. And don't forget about triggers that already exist in the workplace. Do they serve healthy food at meetings, or is it junk food? Are the stairwells clean and brightly lit compared to the elevators? What's in the vending machines? These are all workplace triggers that you can impact.

This client could be classified as being in the agricultural industry, or the beverage industry. It's a vineyard and winemaker in northern California. They had conducted Health Risk Assessments and coaching for high-risk employees for several years before starting to focus on engagement. Like many employers, there is no fulltime wellness person, instead someone from Human Resources has to do wellness along with their main job in benefits. There is not a lot of money for the wellness program and incentives - we're talking tens of dollars per employee and not hundreds of dollars per employee. So it sounds like a struggle - hourly employees with relatively low health literacy and technology access, not a lot of budget, and not anyone's fulltime job. So how did we add engagement? First let me give you the “traditional” numbers on participation and results, and then we'll give you the numbers based on the new engagement metrics. At the start of this year, they ran a weight management program that was focused on engagement. 34% of employees participated in the program, and 80% of them lost weight. In fact, they lost an average of 5.8 pounds each. They also joined a physical activity challenge and completed 288 minutes per week of physical activity. Later this year, they ran a Fruits & Veggies program that was also focused on engagement. The program brought in 17% of the population as participants. Fruits & Veggies eaten went from 1.8 cups per person per day to 2.7 cups per person per day - essentially they made the effort to eat one more fruit or veggie per day. They also took part in a physical activity challenge and averaged 313 minutes of physical activity per week. Now here are the engagement numbers. 46% of the population participated in at least one of these four programs. And they didn't do just one program, they averaged just over 2 programs each. In each program, participants average 65 times when they take a measurable, health positive action. That's 65 units of engagement per participant, per program. That's a lot of engagement! This client went from a wellness program that was focused on HRA's and followup to a program focused on building and measuring engagement. So I hope that makes it concrete about one way to build and measure engagement. No doubt, you will find many other ways to build engagement other than what this client did. But I think if we keep our eye on the ball in terms of how we measure it, we can find many good ways to build engagement.

So now that we're drawing to a close, let me recap what we've said about building, measuring and sustaining engagement. You've all seen your health care costs going up over time, and most of that is due to daily lifestyle habits. That's why we need engagement and why we can't have those once-a-year wellness programs. Each unit of Engagement is a participant taking a measurable action to improve health. If you want to improve the long-term cost picture by changing daily habits, it will take a lot more units of engagement than wellness programs have today. It will take 100 or 200 or 365 units - not just a handful. Next, Intrinsic motivators are needed to generate true yearlong engagement. Monetary incentives will get you an HRA and a biometric screening, but they aren't enough to deliver every-day engagement. Each unit of engagement is governed by the BJ Fogg behavioral model. Each and every time we want the participant to take action, we have to bring together motivation, ability, and a trigger. Most wellness programs need a lot more triggers. We have four suggestions to add more triggers:

  • First, Make sure every program communication includes a call to action.
  • Second, Build in more triggers using automatic email, text message and social media communications.
  • Third, Teach participants to create their own triggers.
  • Fourth, give participants the ability to trigger each other through the program.
Engagement is something we can define and measure. Using the latest scientific models, we can see why we've been so successful at some things in wellness - and light the way to programs that can produce engagement all year long in the daily habits that have the most impact.


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