Are you lost in the world of BCTs, NLP and nudging? Has it been applied to you and do you want to apply it to your business? There is a wealth of resources available on behavior change, but it requires expertise to separate the wheat from the chaff. This flagship article guides you through the process of behavior change and signals the expertise and information that are needed along the way.
Do you recognize the feeling, ‘If people would just listen to me/read my mail/follow corporate guidelines or policies, then…’? This is an everyday example showing that changing behavior is not easy and requires much more than just providing information 1. Corporate investment and engagement in employee health and wellbeing is not as simple as communicating a management decision. In fact, the real challenge comes after the decision has been made. True engagement in employee health and wellbeing initiatives requires insight into human behavior and how to change it.
In order to change behavior, the first question we must ask is, why do people behave the way they do? The answers will differ from one situation to the next, but any solution that you use needs to target the why beneath the behavior you want to change. It is important to note that an individual's behaviors are determined by the combination of the person and his or her environment 2. In acknowledging the multitude of mental, cultural and physical variables in play, we see that there is no one-size-fits-all answer to the question we are ultimately asking: how do we change someone’s behavior?
No behavior change method is a silver bullet. They might even be counterproductive if they are not applied correctly or do not target underlying motivations. Despite good intentions, many attempts to change behavior fail miserably. But, fortunately, such failed attempts teach us important lessons.
Lesson #1: Involve everybody who is involved
A real-life example that teaches us why some of these methods fail concerns attempts to promote influenza vaccination among health care workers. Lehmann and colleagues 3 tested strategies to promote the vaccine among employees in two health care organizations. Workers were randomly assigned to one of two conditions. In the opt-out condition, nurses and doctors received an email with a prescheduled appointment for vaccination, which they could change or cancel if they so desired. The other (opt-in) group received an e-mail explaining that they had to schedule an appointment. In one organization, scheduling the appointments for the employees resulted in more workers getting vaccinated.
However, in the other health care organization, the management team had to cancel the initiative because employee council members felt that the new policy would restrict the decision autonomy of employees. The attempt failed because stakeholder participation – adopting a participatory, problem-solving approach with representatives of the employees – was not secured in the early stages of the experiment. This demonstrates that it is crucial to involve everybody who is involved in both the problem that you try to address and the solution that you want to roll out. This not only concerns representatives of those whose behavior you want to change, but also those involved in decision-making and implementing the solution. In other words, take into account the behavior of relevant people at various levels, because improving employee performance and wellbeing often requires changes at various management layers 4.
Lesson #2: There are no quick fixes
Providing an opt-out instead of an opt-in, as illustrated in the example above, falls under the umbrella of 'nudging.' Nudging is a behavior change method that has been popularized by the behavioral economists Thaler and Sunstein 5. One of the reasons for the popularity of this method is that it might come across as a quick fix – however, it is not. Thaler and Sunstein define nudging as any aspect of the choice architecture that alters people's behavior in a predictable way. This must be accomplished without forbidding any options or significantly changing their economic incentives. It's easy to see why this method is so popular when we consider that it is both possible and legitimate for private and public institutions to affect behavior using nudging without violating freedom of choice.
In another real-life example, multiple environmental changes were made to a stairwell in an office building. Stair rise banners with health messages were placed on the steps, featuring language such as, ‘take the stairs,’ ‘exercise prevents diseases,’ ‘saves you time,’ ‘keep fit,’ ‘be active,’ ‘free exercise’ and so on. Light-hearted posters in the stairwell encouraged stair use with humorous messages. The ventilation system was changed in such a way that the doors could remain open to allow a clear view on the stairwell. In addition, the walls were painted in a green shade, which is associated with peacefulness, rest and freshness. As a result of these changes, total stair use increased by 8.2%, and these effects remained stable over time 6.
Despite the success of nudging in this example, it is not a quick fix. I work on the interface of behavior change and technology, where new technological solutions are often presented as the solution to a problem. A fairly recent example of techno-optimism is the introduction of digital contact tracing to control the COVID-19 pandemic. The use of a contact-tracing app could slow the virus's spread by reducing the time between infection and quarantine, and it could inform people who are infected but not yet symptomatic 7.
This idea behind a contact-tracing app is fairly simple, from a technological point of view, and was met with a lot of enthusiasm. However, it also led to public debate about the legal (e.g., data protection, privacy) and ethical (e.g., proportionality, accessibility) 8 ramifications of using the technology. The main issue was that these concerns might negatively affect adoption by citizens. However, the pilot study in the Netherlands showed that the more important challenges – from a behavior change point of view – were at an organizational level. For example, if a citizen gets an alert from a contact-tracing app, does the health service employee then know what to do? And can all citizens that receive an alert get tested?
So, in short, technology is not a solution, but a possible means to an end. Do not start with a solution in mind. Focus on the problem, the behaviors of everyone involved (see first lesson) and – most importantly – why they behave as such, before jumping to solutions.
Why do people behave the way they do?
To increase the likelihood of successful behavior change, any solution that you use needs to target the underlying reasons for the behavior. These motivating factors are called 'determinants of behavior,' and theories can be useful to gain insight into these determinants. The Reasoned Action Approach, for example, is a commonly used theory 9 that provides an overview of important determinants for reasoned (not necessarily rational) behavior. In short, the Reasoned Action Approach states that intention, the readiness to engage in the behavior, is the most important predictor of behavior.
This intention is shaped by three determinants: attitude, perceived norm and perceived behavioral control. We can define attitude in this context as perceived consequences and experiences related to a behavior (e.g., If I follow this safety protocol, I'm less likely to be injured). The second determinant, perceived norm, is the perceived social pressure to perform a behavior (e.g., My colleagues follow the safety protocol). And third, perceived behavioral control, is whether people think they are capable of and have control over performing a given behavior (e.g., Following a safety protocol is hard to do when I’m in a hurry).
These determinants are relevant to all types of reasoned behavior, but we need to dig deeper, into the beliefs underlying these determinants. These beliefs might differ per behavior. For example, the reasons people think they are capable of following a safety protocol most likely differ from the reasons people think they are capable of going to their work by bicycle. However, these beliefs underlie the same determinant; perceived behavioral control. Insight into determinants is crucial to behavior change. To explain why, allow me to provide a crash course on learning processes.
A crash course on learning processes
First of all, behavior change is a misnomer. There are not six 10 or 93 11 tricks that can be applied to change behavior directly. All overt behavior results from activation patterns of firing neurons in the motor cortex. And those activation patterns in the motor cortex are the result of activation patterns elsewhere in the brain 12. When people learn, those activation patterns of firing neurons change. Christian Lohmann, of the Netherlands Institute for Neuroscience, compares this to dating.
Neurons mess around and test their partners. Most of the time they decide that it is not going to work out, but eventually they find stable connections 13. This is in line with a reinforcement learning perspective on behavior: people acquire behaviors by learning to obtain (real or conjectured) rewards and to avoid punishments 14. The brain takes these rewards and punishments into account and then decides which action to take based on ‘computation’ of value (i.e., expected rewards) 15. These values might be based on various rewards such as feeling comfortable or in control over a situation, gaining status or belonging to a group 14.
As the brain developed over time, learning itself also evolved. Capuchin monkeys, for example, are able to sort objects based on their shape 16, and this way of learning abstract concepts is also used by humans. Thankfully, we do not have to think deeply each time we see a pen or a car in order to decide what it is and what we can do with it. That same learning process, however, can also make it difficult for us to appreciate nuance. It can cause us to pigeonhole others. So, these learning processes are not informative regarding what we learn, but they provide insight into how we learn. It is essential that we understand this when using methods aimed at behavior change. When these methods are based on one or more of these learning processes, people are able to learn something – and change where needed 17.
No method can guarantee behavior change
Planning frameworks 18 guide you step by step through the process of development, implementation and evaluation of solutions that target the underlying reasons for the behavior. Working in such a systematic way is crucial to finding solutions that work; it increases the likelihood of success, but note that it's not a guarantee. In general, don't trust anybody who guarantees results. While such a pledge might make their method popular, it doesn't mean it actually works.
Personal development training based on Neuro-Linguistic Programming (NLP), for example, is widely embraced 19. NLP is a therapeutic technique used to detect and re-program unconscious thought patterns and behavior in order to alter psychological responses. The creators of NLP have claimed that there is a connection between the neurological processes (neuro), language (linguistic) and behavioral patterns learned through experience (programming). As such, it can be used in business, education and mental health treatments 20. However, after more than three decades, research did not establish any evidence for its efficacy that is not anecdotal 21.
Which behavior change methods should you use?
For behavior change to succeed, it is important to use behavior change methods that are able to target determinants of that specific behavior. The learning processes introduced above are helpful to understand which behavior change methods to use in what situation. For example, reflective learning enables people to learn from mistakes made in the past and make better plans for the future (e.g., because they can anticipate difficult situations). ‘Implementation Intentions’ is a behavior change method that employs people’s ability to plan and aims to help them with this 22.
In one exemplary study, women attending the Weight Watchers program were randomly assigned to one of two groups 23. In the control group, women attended the weekly meeting of the Weight Watchers program. This was the same in the experimental group, but on top of that, there was one extra session in which women had to write down a detailed meal and exercise plan for the upcoming week. After that, women had to specify what they would do in situations in which it is difficult to stick to their plan (e.g., when it is raining or when attending a party). In other words, the experimental group had to write down specific intentions to implement change. At two-months follow-up, women in the experimental group had lost twice as much weight in comparison to women in the control group (4.2 vs. 2.1 kg.). This is an example of how implementation intentions are applied in practice. However, in this example, implementation intentions can only work because women participating in Weight Watchers are already motivated. In fact, having an intention to change is a condition for this behavior change method to work optimally 24. This is exactly why it is important to gain insight into determinants before choosing a behavior change method.
The supplementary material provided by Kok and colleagues 24 is very useful as it uses tables to lay out clearly which behavior change methods are linked to specific determinants. This is helpful in choosing behavior change methods that are relevant to use in a given situation. For example, providing arguments might be a possible way to change people’s attitudes. However, when lack of perceived behavioral control appears to be an important reason why people don't engage in a certain behavior, then guided practice is a more appropriate behavior change method to use in that situation.
How do we apply behavior change methods?
The link between determinants and behavior change methods might come across as a simple mix-and-match exercise that can be used when selecting appropriate behavior change methods. However, applying behavior change methods correctly is a different story. Using behavior change methods in practice requires adherence to their parameters for use 24 . These parameters are crucial to successfully engaging the learning processes necessary for behavior change. For example, a method people often use when they want to initiate behavior change is, ‘Let’s confront people with how risky it is if they [insert undesirable behavior here].' This commonly used behavior change method is called ‘fear arousal.’
A well-known example of fear arousal is the use of scary pictures on cigarette packages. The first parameter for use of fear arousal is that people must perceive a severe threat (e.g., suffering from lung cancer). Secondly, they must consider themselves susceptible to this threat (e.g., it could happen to me). Thirdly, they must at the same time believe that the suggested behavior (e.g., quitting smoking) can effectively diminish the threat. And lastly, they must be confident that they can successfully conduct the behavior 25. A summary of available evidence on fear arousals shows that when threat is increased, but people do not feel confident to successfully conduct the required behavior, then this behavior change method might even decrease the likelihood of behavior change (e.g., they deny risks associated with smoking) 26. So, merely communicating the risks related to a certain behavior is not sufficient to change behavior. In fact, when people do not feel confident to successfully conduct the required behavior, it might be wiser select behavior change methods targeting this determinant.
This sounds complicated. How do I do this in practice?
Use planning frameworks to guide you through the process of analyzing a problem and choosing behavior change solutions. This is mostly done by raising questions that need to be answered (e.g., what are the determinants of the behavior of interest?). As you move through your planning framework, core processes help to answer these questions in a systematic way 27. The use of core processes is essential, because too often people claim to have reviewed empirical literature, applied theories and collected additional data, but in fact have done these tasks incompletely and selectively. This can result in a missing link between determinants and behavior change methods or incorrect application of those methods 28.
Using core processes to turn questions into solutions
Core process #1: Brainstorm possible answers
Asking the right questions at the right moment is the point of departure for brainstorming potential solutions. Brainstorming is a core process that includes consulting with experts and primarily involves free association with the aim of generating as many answers as possible in response to a question. It's a low-stakes activity, as answers that are poorly supported can later be discarded. This is in line with Linus Pauling's adage that ‘The best way to have a good idea is to have lots of ideas.’ In formulating provisional answers, experts typically draw on both theoretical and empirical knowledge, whether consciously or not. Brainstorming can lead to multiple answers and ideas, and there is no reason to favor a data-based idea over a theoretical one. In other words, brainstorming does not lead to final answers, but it might guide the search for evidence.
Core process #2: Review the evidence
Supporting or refuting potential answers by reviewing evidence is the next core process. Make use of evidence that is already available (e.g., through Google Scholar or other databases) instead of reinventing the wheel. It's useful to note, however, that different types of studies provide different types of evidence. For example, a review study might be a useful starting point, as it summarizes available evidence on determinants of pro-environmental behaviors in organizations 29. Such a summary is by definition more general in nature. However, a single study might provide more in-depth insight into a specific behavior (e.g., work-related travel behavior among Dutch office workers 30). It is important to first review evidence before relying on theories that are – by definition – more general in nature.
Core process #3: Find theoretical support
Your next step is to find theoretical support and make the provisional list of answers as extensive as possible. This needs to be done before conducting any new research and making decisions. Applying theory to real life problems is comparable to completing a jigsaw puzzle. Multiple theories – or parts of the puzzle – need to fit together to provide a complete answer to a question 31. Limiting the pool of candidate theories too soon may lead to inadequate answers, or worse, lead to conclusions being drawn that are counterproductive.
It's wise to complete all three of these core processes before conducting new research. A very practical reason is that collecting additional data requires a lot of resources (in terms of time, expertise and money), and why go to all that trouble if the data you need already exists? All evidence and insights that are available should be used before conducting new research. After that, you are ready to summarize and complete the provisional list of answers into a working list that is supported by sufficient evidence.
Consult with an expert
There are various ways to work through these processes – sometimes it might be as simple as a couple of hours of meetings, other times it might be a full-blown project lasting several months or even years. When there is time pressure, however, it is better to go through all core processes briefly instead of focusing deeply on just one or two processes (e.g., only using theory). This is because these core processes are iterative in nature. Their findings build upon each other. Moreover, these core processes make clear that expertise (e.g., an applied psychologist) is required when developing and implementing behavior change solutions. If this expertise is lacking, then in the best-case scenario, you are reinventing the wheel. It is more likely, however, that even with good intentions, you are coming up with ineffective solutions and wasting resources. In the worst-case scenario, the solutions might even be counterproductive. So, from a corporate investment point-of-view, it is wise to seek out behavior change expertise to improve employee health and wellbeing.
Professor Rik Crutzen is trained as a psychologist and holds a chair in behavior change & technology at Maastricht University, The Netherlands. He is one of the world-leading experts in Intervention Mapping; a systematic way for development, evaluation, and implementation of behavior change interventions. Besides his expertise in behavior change in general, the focus of his work is on how we can use technological innovations to improve both reach and efficacy of behavior change interventions.
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