Disruption of the 'Usual' -

Rethinking Behavior Change and

Communication in Nutrition

Education

R. Craig Lefebvre, PhD

chief maven, socialShift

Lead Change Designer, RTI International

Research 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 Change

Stages of Change Health Belief

Model

Social-

Cognitive

Theory

Diffusion of

Innovations

Social

Networks

Precontemplation Susceptibility Reciprocal

determinism

Relative

advantageOpinion

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

Rational

Deliberate

Forward looking

Gets loss in analysisEmotional

Instinctive

Immediate needs

Lazy

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

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

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

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

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 Adopters Early Majority Late Majority Laggards

Venturesome Respect Deliberate Skeptical Traditional

High 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

leaders

Groups

Adding or

removing

members

Bridging

groups

Rewiring

groups

Network

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%

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 marketingSocial marketing

benchmark criteria

Keys to increasing healthy eating using social marketing

Behavioral objective Evaluate healthy eating using multiple behaviors

Tackle single behaviors serially over time

Audience segmentation Identify different groups

Serve each group with a unique solution

Formative research Conduct formative research

Research must be consumer oriented

Exchange Offer salient benefits – short-term benefits can be more salient than long-term

benefits

Consider 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 analysis

Know 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.