The healthy choice How behavioral factors create influential health campaigns

By designing health communications using behavioral economics principles, governments and organizations can go beyond raising awareness to “nudge” people to make more healthful choices.

Introduction

Many public health concerns are perpetuated by less-than-ideal behaviors that collectively are very costly. Much of the illness, disability, and premature deaths in the United States can be linked to behavioral decisions such as tobacco use, insufficient physical activity, poor eating habits, and excessive alcohol consumption.1 The United States spends substantially more on health care—at least five percentage points more of its GDP—than other developed countries.2 Chronic and lifestyle diseases—most prominently diabetes, cancer, and heart disease—account for the large majority of health care costs, with 86 percent of all health care spending in 2010 on people with one or more chronic medical conditions.3 Individuals make behavioral decisions that may be based on incomplete information and their own experiences, habits, opinions, and beliefs, which are often based on intuition and emotion.

The United States spends substantially more on health care—at least five percentage points more of its GDP—than other developed countries.

FedeDUP_958_Featuredral and state governments have taken a variety of actions to promote healthy decisions and behaviors, enacting policies, laws, and regulations to help mitigate “unhealthy” choices and encourage “healthy” choices. Such interventions (incentives and disincentives) act as guardrails and signposts for health decisions. But, on their own, they do not—and cannot—guarantee that people will make healthy decisions. Trying to make bona fide behavior change happen, along with improved health outcomes, demands additional measures and outreach efforts.

The good news: Organizations and governments can draw upon a long and established history in implementing such measures and efforts to improve people’s health. When based on sound theory and principles of behavioral economics, health communications are instrumental to effecting change that can improve health outcomes. In this paper, we explore how communications that leverage these insights can be particularly effective in raising awareness, conveying healthier options, and influencing decisions. The results can include sustained behavioral change, healthier outcomes, and, ultimately, health care cost savings.

A Deloitte series on behavioral economics and management 

Behavioral economics is the examination of how psychological, social, and emotional factors often conflict with and override economic incentives when individuals or groups make decisions. This article is part of a series that examines the influence and consequences of behavioral principles on the choices people make related to their work. Collectively, these articles, interviews, and reports illustrate how an understanding of biases and cognitive limitations is a first step in developing countermeasures that limit their impact on the organization. For more information, visit http://dupress.com/collection/behavioral-insights/.

Health decisions are different

Especially when it comes to making good health decisions, we need all the nudging we can get:4 Knowledge and awareness campaigns alone are rarely sufficient to help us make the right choices. In fact, awareness campaigns sometimes bring unintended negative consequences. Such was the case for the Drug Abuse Resistance Education (DARE) campaign launched to help keep youth from using drugs. In 1992, researchers at Indiana University found that although the DARE intervention successfully communicated the hazards of drugs, students who completed the DARE program had significantly higher rates of hallucinogenic drug use later in life than those not exposed to the program.5 This unintended result was confirmed by research at the California Department of Education in a 1995 report6 and by US Surgeon General David Satcher in 2001.7

Viewed through the lens of behavioral economics, it is clear that individuals are often not entirely rational when it comes to weighing the consequences of their personal health decisions. They tend to make errors in judgment due to a variety of biases in their decision making, and they do not always know how to appropriately apply the information available to them. Individuals also tend to be influenced disproportionally by cost, and they may frequently misjudge the relative risk of negative outcomes. These shortcomings can be overwhelming, especially when combined with the staggering amounts spent marketing “poor” choices to individuals. Tobacco companies, for example, spend $8.37 billion annually ($23 million per day) in the United States alone encouraging consumers to buy their products.8  The fast food industry is just as powerful, especially when marketing to children. In 2012, preschoolers saw an annual average of 1,023 fast food ads—that’s 2.8 ads per day encouraging “easy” food choices. That year, 60 percent of fast food restaurants increased television advertising to older children over the previous year.9  These companies use their vast resources to sway behavior through “availability,” a decision heuristic that we will describe in more detail later—for now, it is how companies make their product top of mind when a purchase decision is required.

Increasing weekly caloric intake by 1,500 calories (the equivalent of approximately three to four cheeseburgers) might not result in a significant weight gain (more than five pounds) for one to two months.

Public health communications, competing for attention, often aim to incorporate the type of emotional appeals that work so well in consumer advertising. However, relying solely upon creative strategies to make healthy options appealing limits opportunities to impact behavior. This is because health decisions differ from general consumer purchase decisions in important and fundamental ways:

  • Individuals often develop poor health habits over time and see mostly delayed impacts. Individuals rarely see the immediate impact of unhealthy decisions. For example, increasing weekly caloric intake by 1,500 calories (the equivalent of approximately three to four cheeseburgers) might not result in a significant weight gain (more than five pounds) for one to two months. With this delay, many individuals may not even realize that their actions are resulting in negative health consequences—or which of their decisions might have led to any problems they might be facing. This, coupled with a “present bias” (the propensity to favor something in the present at the expense of something in the future), often contributes to poor decision making in health-related areas.Furthermore, the consequences of a single health decision—for example, whether or not to smoke—can affect individuals and future generations for years to come. Unhealthy choices and behaviors are not innate—they are learned: Poor health behaviors can be passed with relative ease from parent to child, both within and across cultures. For example, a National Institutes of Health study found that children with parents who smoke are significantly more likely to adopt the habit than the children of nonsmokers.10  Similarly, children with obese parents are at a much higher risk of being obese themselves, due to not just genetics but also learned dietary choices and behaviors.11
  • Individuals may not realize their everyday decisions are actually health decisions. In matters of health, choices often masquerade as decisions of convenience or taste rather than health decisions. For example, during your morning commute, a radio ad encourages you to try a new breakfast sandwich. In this context, you are likely to see this purchase as a quick and convenient solution to morning hunger. If, however, the decision is framed as a health decision, you might instead opt to delay your purchase until you reach a grocery store (perhaps down the road) and make a healthier choice, however inconvenient. A health decision often requires an individual to decrease or abstain from a particular behavior, while traditional product marketing promises to solve short-term challenges through “buying.” Individuals influenced by marketing are less likely to realize that what appears to be a one-off choice can eventually turn into a lasting poor health habit, especially if that drive-through is irresistibly convenient. Repeated patterns of poor behavior perpetuate until reversing or modifying them would mean abandoning an established habit or family tradition. Individuals who continue to make poor decisions are more likely to develop chronic conditions later in life.12
  • Reaching people when and where they make their choices is difficult. Unlike most consumer actions, people often make health decisions on the fly—selecting hastily from a restaurant menu, in the office lunchroom in front of a box of doughnuts, at a neighbor’s cocktail party when invited outside for a smoke, or in the kitchen while deciding what to eat and drink for dinner. Because health decisions are often made in familiar settings and without expert input, helping instill healthier decision-making skills and providing sound and actionable information are both challenging and critical. They mean that the foundations of good decision making must be established before people face the need to make a choice.

How behavior-change theory impacts health decisions

Public health scholars and social marketing experts have long recognized the value of scientific research based on the nature of certain behaviors, choices, and the psychology underlying these behaviors. Behavior change theories guide our understanding of why people make the decisions they make, what key levers or hooks can be manipulated to help effect change, what programmatic strategies are most likely to resonate with people, and how to measure successful efforts. Below are several theories that governments and organizations can incorporate into health communication strategies to not only reach more people but also change behavior—and therefore improve health outcomes over the short and long term.

An example from the market: Consumer Information Processing model

The Consumer Information Processing (CIP) model, developed by Michael Hagerty and David Aaker, is based on a simple premise: While people of course require information about the decisions they make, such information is just a part of the decision-making equation.13 CIP theory reflects a combination of rational and motivational ideas: A consumer may use information in an analytical way, but it is motivation that drives his search for that information and how much attention he pays to the issue in the first place. The central assumptions of CIP are that (1) individuals are limited in how much information they can process at a given time; and (2) in order to increase information’s usability, individuals unconsciously combine bits of information into “chunks” and create decision rules—also known as heuristics—to encourage faster and easier, if not better, choices.

Decision-making heuristics

Researchers refer to the CIP’s decision-making rules component as heuristics, or rules of thumb—a foundational concept in behavioral economics.14 Psychologist Daniel Kahneman and his colleagues identified several heuristics that individuals naturally use to reduce the complexity of decision making. Some heuristics that play a key role in influencing health-related decision making are representativeness, availability, anchoring, and adjustments.

  • Representativeness: People make decisions based on the extent to which they believe an object or thing “A” belongs in a group “B”; their minds attempt to answer the question, “What is the probability that object A belongs in group B, or that event A leads to outcome B?” For example, a diagnosis of post-traumatic stress disorder (the object A) may relegate the patient to membership in a stigmatized group, B. Medical authorities have struggled to change this perception, considering many people’s ingrained association.15
  • Availability: Availability (mentioned earlier) is a judgmental heuristic that is based on the ease with which people can bring particular things to mind. Similar to the cues to action construct in the Health Belief Model (explained below), availability is a useful clue for assessing choices, affecting a decision maker accordingly. For example, one may assess the personal risk of a heart attack by recalling heart attacks suffered by friends or acquaintances. The availability heuristic works because people usually recall instances of large classes more clearly and quickly than instances of less frequent classes, or they imagine likely occurrences more readily than unlikely ones.
  • Anchoring and adjustment: Anchoring is the impact that a starting value or an understanding has on the ultimate decision a person makes. Adjustment is the process of how someone incorporates new information into her decision-making process and uses that information to shape her final decision. Anchoring and adjustment occur in the decision-making process not only when the starting point is offered but also when the decision maker bases her decision on incomplete or inaccurate information. For example, a woman’s doctor may recommend that, based upon family history, she undergo genetic testing for the BRCA gene.16 Initially, the patient may consider the testing worthless because she attributes her family history of breast cancer to hormone replacement therapy rather than a genetic tendency (she is anchored in this belief). However, after reviewing informational literature and speaking with individuals who have undergone testing, she revisits her view (adjustment). In making this decision, she has demonstrated principles of anchoring and adjustment.

CIP’s key concepts and processes clarify why people unconsciously use or fail to use the information that is available to them; this understanding gives public health experts and social marketers the tools to design informational strategies with a better chance of successfully and positively motivating behaviors. According to the CIP framework, before people will take in and use information, it must be (1) available, (2) seen as useful and new, and (3) processable, or format-friendly. Figure 1 presents the CIP model’s elemental concepts, definitions, applications, and tactics.

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The CIP model’s decision rules/heuristics are incorporated into a variety of behavioral health messaging to influence positive action.

Applications in public health: The Health Belief Model

A group of social psychologists at the US Public Health Service developed the Health Belief Model (HBM) in the early 1950s to help them better understand health decision making;17 over the succeeding decades, it has become one of the most important frameworks of shaping public health policy. Although the HBM predates CIP, incorporating the decision rules and heuristics of the CIP model can enhance the HBM’s effectiveness today.

The model posits that people weigh four interrelated constructs in their decision making that, together, help to articulate a person’s “readiness to act”:

  • Susceptibility: How likely is a bad outcome?
  • Severity: How bad will it be if it happens?
  • Benefits: What will you get out of making a good decision?
  • Barriers: What is keeping you from making a good decision?

An additional construct, cues to action, involves activating that readiness and stimulating overt behavior. The HBM can be useful in analyzing the action, inaction, and decision-making priorities that accompany a person’s health-related decision; it can guide the effort to understand why individuals make decisions to act (or not) in the hope of making a change (such as losing weight or trying something new). The model is most appropriate when the problem behavior or condition is associated with issues of motivation, since that is its central focus, but the concepts can be stretched to relate to social or economic issues that are not health-related decisions. Figure 2 presents the HBM’s underlying constructs, with examples of how each relates to a health decision.

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Since the HBM is rooted in understanding perceived beliefs, those decisions can benefit from the incorporation of the decision heuristics of CIP—especially when our heuristics sometimes let us down and make us more susceptible to bad choices. Decision makers with a heightened awareness of these challenges can improve their outcomes by taking into account the inherent weaknesses in our human thought processes—and thus become more likely get to the root of our motivating behaviors.

Transforming theory into action

As do many other types of communication, successful behavior change campaigns begin with defined, measurable goals, in which organizations use formative research—along with audience characteristics and psychographics—to tailor interventions or communications to meet those goals. Without identifying the specific desired behavior changes, organizations cannot begin to effectively develop campaigns that make those changes happen. Once the campaign establishes goals, and designs and deploys interventions, it must incorporate quantitative and qualitative monitoring to measure effectiveness. With these outcome data in hand, campaign designers can more effectively adjust strategies. Below, we illustrate several examples of how campaigns can use these techniques to change behavior.

Strive to Beat 5 campaign: The Health Belief Model in practice

The Strive to Beat 5 campaign targeted a population of 110 young professionals at Deloitte with the goal of increasing practitioners’ fruit and vegetable consumption and related nutritional knowledge over four weeks during the fall of 2012. Although experts have long associated a diet rich in fruits and vegetables with a decreased risk of heart disease, stroke, high blood pressure, diabetes, and some cancers, fewer than 1 in 10 Americans consume the government-recommended amount of fruits and vegetables.

This particular study selected participants based on the messaging’s potential maximum impact, based upon where the subjects lived and worked, along with their frequency of dining out. Researchers then randomly assigned participants to an experimental group (receiving enhanced messaging) or control group (receiving standard messaging).

Before launching the communication campaign, the team conducted a baseline study of the population’s relevant data, including demographics and daily environments. To collect information on young adults’ eating habits, the team reviewed environmental and social determinants, as well as epidemiological studies on health habits, nutrition, and obesity; they also gathered research on the effects of corporate wellness and cost-savings programs on eating habits. This baseline information provided key insights, which the researchers incorporated into their behavior change messaging, addressing the perceived susceptibility, benefits, and barriers—all factors of the HBM—to these individuals eating more fruits and vegetables.18

The researchers delivered to both groups a behavior change message that both illustrated the visible health benefits of including more fruits and vegetables in a daily diet and targeted the barriers to doing so, such as making healthy purchase-point decisions and planning consumption throughout the day. The members of the experimental group also received enhanced messages promoting eating fruits and vegetables (such as providing instructions on how to easily prepare them) and provided examples of the visible benefits, such as weight loss. The messaging incorporated the availability, anchoring, and adjustment heuristics of the CIP model so that healthy decisions continued to be “top of mind” for the group. Rather than the encouraging and instructive messages detailed in figure 3, researchers gave the control group only basic reminders to complete a daily tracker.

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Both groups were sent the messages at the same time on a daily or weekly basis via email and additional digital communication vehicles (figure 4). Researchers asked all participants to complete individual food trackers and sent intervention compliance–based reminders. Progress toward each group’s improved fruit and vegetable consumption and knowledge goals were monitored regularly through the use of food trackers, inbox monitoring, pre-surveys, midpoint analyses, and post-surveys. These digital methods provided data and insights that traditional communications measurement would likely have been unable to offer.

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The results, detailed in figure 5, showed that participants in the targeted intervention group increased their desired behavior (eating more fruits and vegetables) by nearly 33 percent during the study, while the control group showed no noticeable increase.19 Researchers attributed this change in behavior to the targeted messaging, which specifically addressed barriers, susceptibility, and cues to action—all important components of the HBM.

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Using behavior change methods to increase contraception use

A study of reproductive health in Nigeria and India provides an additional illustration of how behavior change communications can change perception and the awareness of health decision making, sometimes more effectively than traditional social marketing efforts.20 The Society for Family Health’s condom program in Nigeria and the Commercial Market Strategies project’s oral contraceptive (OC) program in India each marketed several different brands of condoms or OCs to household consumers in an effort to increase overall use. When brand-specific promotions (such as those promoting the low price of condoms) proved unsuccessful in increasing general contraceptive use, the organizations developed behavior change communication strategies for both countries.

Both behavior change campaigns sought to increase the use of either OCs or condoms, improve attitudes and beliefs toward reproductive health and pregnancy-prevention methods, and ultimately increase condom and OC sales. These programs and campaigns could play a key role in providing family-planning services and preventing the spread of sexually transmitted diseases and human immunodeficiency virus (HIV). In the Nigerian portion of the study, researchers incorporated a behavior change model developed by Population Services International that included core elements of several established behavior change models (including the HBM and the Transtheoretical or “Stages of Change” model, shown in figure 6), adding a temporal component to the decision-making process.21 The Indian portion of the study incorporated a decision timeline model with five phases: precontemplation, contemplation, preparation, action, and maintenance. An outline of the messaging strategies, applied to these phases, is below.

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Both programs incorporated a variety of messaging strategies and vehicles—including radio and television dramas, billboards, and roadshows—all aimed at increasing awareness of HIV and the associated risks of not using condoms to protect against HIV. Roadshows presented interactive communication techniques for selected target audiences in places where people regularly engaged in high-risk behavior. During these events, performers acted out HIV/AIDS-related scenarios, responded to audience questions, and distributed informational materials and condom samples to participants. (Informed by the CIP model, the programs considered the decision-making heuristics that have led to adverse health choices in the past and used these insights to fuel the intervention strategies.) Both programs also incorporated multiple rounds of household survey data to closely monitor program outcomes.

Following the campaigns in the two countries, condom sales doubled over a period of a decade, and attitudes toward reproductive health methods improved.22 Constant monitoring helped both Commercial Market Strategies and the Society for Family Health capture meaningful data and understand the impact of their communications. While there was a notable time lag before measurable change occurred in knowledge and attitudes attributable to method use (which is common in interventions targeted at changing perceptions and behaviors), the results indicate that behavior change communications can help counter stagnating reproductive health product sales in markets accustomed to traditional social marketing focused on selling products rather than changing behavior.

Conclusion

 Communication campaigns, whether product advertising or public health promotion, generally aim to achieve lasting behavior change. As demonstrated in our three examples, communications that deploy effective behavior change models and data-driven strategies can achieve change in human perception and behavior. These strategies hold significant importance for governments and organizations striving to influence health decisions, where competition is particularly fierce: Influencers surround us with continuous advertising, and years of learned behavior and social pressures tempt us away from “healthy” decisions. Leaders wishing to promote health programs or looking to mitigate the impact of increasing health care costs may consider the following course of action to develop effective communications within organizations:

  • Explicit goals: Competing interests are vast, and the resources to enact change are often limited, so clearly articulate what you hope your campaign will achieve.
  • Choose a model: Leaders in the behavioral field have cultivated models to help make your message heard—use these to influence. If attempting to help motivate consumers in a confusing or noisy environment, consider implementing the HBM (with the help of CIP to inform how people process their decisions).
  • Monitor and test: When implementing a new campaign, monitor its effectiveness. These approaches can help organizations better understand their communications’ impact throughout a campaign’s life.

Whether you’re a government agency advocating citizens to vaccinate their kids, or a corporation trying to reduce employee health care expenses through quit-smoking programs, behavior change models can help you better target and communicate messages, potentially resulting in more people hearing and acting upon them.

Deloitte Consulting LLP’s strategic communications framework drives the development, execution, and measurement of evidence-based, data-driven communications to achieve specific behaviors and outcomes. It is based on social marketing and heuristic methods that have been applied to communications campaigns across the federal and public health landscape. Contact the authors for more information or read more about our strategic communications services on www.deloitte.com.