Hello, hello, and welcome to the behavioral design podcast hosted
by Samuel Salter. Hi Sam, hello.
Hello and myself Eileen holsworth, Sam.
I have a question for you. Are you more of a treadmill or a
rower person at the gym? Yeah, I'm not, you know, Article
roller. I'm one of those people that
really usually, there's like one rolling machine at the gym that
no one uses and I guess I'm depressed.
It's the exception. Yeah, yeah, I would say I align
with the with the most popular sentiment of Terror when looking
at the rowing machine. It's definitely not definitely
not something I've ever even. I don't think I've even tried
it. Like I do I like doing the the
weights that sort of Simulate the version of rowing, but the
actual machine is horrifying, well, fun fact in Sweden, that
is actually very similar, kind of machine.
Always look so different, but where it's a machine used for,
like, long-distance skiing. So you have like this two ropes
where you can like, skiing way and so that's, that's yeah.
That's the funniest one. And even one thing I saw today,
given that now we have clear the roads from snow.
I saw someone skiing with artificial skis with wheels to
work and so that's something you can see here in Stockholm.
Yeah yeah. How about you?
What do you what do you end up going from the gym?
You you said treadmill or something else.
What is your cardio equipment of choice?
I'll be honest. It's been a while since I've
been to an actual gym but back in the day.
Yeah, yeah, I definitely I definitely would consider myself
more of a treadmill person. I like to just Just tune out do
a little Temptation bundling and hit the treadmill.
But in terms of skiing I'm definitely more of a downhill
skier than a cross-country. Yeah.
I don't like I don't understand really where the fun is in
cross-country. Well yes it's a good question.
Usually one of the fun Parts with social norms in Sweden with
cross-country skiing is that you know you have tracks obviously
you go down and so You want to kind of keep those tracks clean
as I usually clean track and then beside the track is kind of
more of a messy path. You can also go.
And so the clean track is the best place to be obviously.
And in Sweden is the person behind that has the right to
stay in the track. And so if you're skiing and then
you have some quicker coming behind you, they can scream at
you pretty much get the F out of the way and you You don't have
to be like. Okay okay, yeah.
And so in Swedish, the word is used for sport.
This means like out of the track and so you can often times hear
hear, even if you're in the woods, that happen to have a ski
track, you can just hear someone screaming in the woods and, you
know, that's okay. People are staying.
All right, let's get to it. Let's talk about about this
episode. We have an oh yeah, there's some
have to Yeah, we also, we're here for a podcast, not just
catching up, just so we talk to me test.
Patel he studies nudges and gamification as a means of
improving health and me, touch founded and led the pain
medicine nudge unit. You've probably heard of it and
is currently the vice president for clinical transformation and
the national lead for Behavioral insights at Ascension so fancy.
Yeah, very and we discussed quite a few things including
Being as always, you know how people design can be explored in
the wild specifically when it comes to encouraging healthy
behaviors. And so we explored topics of
gamification and also when it came to be on kind of just
encouraging exercise. A little bit seeing how we can
use people science when it comes to Health Care overall
specifically as the product Deep dive we dive into.
Jim's hands are Random discussion previously.
And so it's not as random as you thought.
Exactly. So, you'll get a chance to hear
what Natasha to say about how we can optimize the gym experience,
using behavioral design principles.
Okay, and lift up those dumbbells, and let's get episode
started at Troy So I'm very excited to say,
welcome attached to the behavioral design podcast, thank
you for having me. We're so excited to chat with
you today. We have a lot of really fun
topics on the agenda. I want to jump right in and talk
a little bit about behavioral design in the wild.
So For Better or Worse, a lot of people have been applying
Behavioral Science in the real world and I know you have a lot
of experience with this you know, both in the academic.
Each side but also in you know doing behavioral design and you
know whatever you want to call it Behavioral Science, very real
economics and so on affecting real people and I'm curious if
you have a favorite example of either good behavioral design or
you know where things have really really gone wrong bad
behavioral design. Yeah that's a good question.
I you know my favorite example is the kind of project or
highlight that really Started my whole career and using
Behavioral Science to change health and Healthcare delivery.
It's around. Prescribing generic medications
versus brand name medications. Generic medications are exactly
the same as brand name medications but they're much
more affordable. They're cheaper her patients
cheaper for the insurance company's Health Systems.
All around is a win-win and their data to show that people
take their generic medications for a longer and more reliably
than their brand-name prescription because they're
probably more portable. And we were wrestling with this.
When I was at Penn Medicine, probably almost a decade ago now
and the health system was struggling to get clinicians to
prescribe the generic medication and every when you talk to a
clinician I said oh we want to do this then when you know it's
the right thing for our patients we're going to try as hard as we
can to help Grand rounds and get clinician feedback on their
performance. But when you look at the
electronic health record, we found that it was like you had
it made a jump through hoops to prescribe the generic medication
and clinicians only have 10 to 15 minutes with patients in
which they have to do a lot of stuff from time.
There's many medications. Instead of ordering.
And so it was really hard. And so we tried a couple of
things in a pilot test with the internal medicine practices.
One was to hide the brand name prescriptions on the first page,
you could still get to them by clicking an extra box.
We found that work a little bit at boosted.
Generic prescribing from 75 to 80 85 percent.
We tested a couple other versions but then ultimately the
version that launched across the health system and had a huge
impact, was basically making generic prescriptions the
default and then Adding a check box on the screen at the bottom
left and if you check that box it would go to the pharmacist as
they brand name prescription. But if you didn't, it would go
as a generic prescription. And what was interesting was
before, all of the prescribing went to the electronic health
record. That's what a paper Prescription
Pad look like. Type and added that checkbox
feature and the generic prescribing right with him, 75
percent to 99 percent overnight and still sustain that way.
Now, you know, a decade later and over the first two years
they had about 32 million dollars in unnecessary cost.
Just for the top 100 medications and we prescribe thousands of
medications. So the potential benefits are
huge. Default started again, yeah.
But I have to say this is one of my all-time favorite examples of
favorable design. Of course, This is something
that's, you know, very close to home for you.
Um, why can't we just use default for everything?
Wouldn't that be the dream that, you know, if you can use a
default that's typically where we go through, we think of it,
you know, the nudge intervention ladder.
That's often how we come up with interventions and default, you
know, are at the top of nudges right below and you know,
incentives on the broader a ladder.
There's a couple challenges in healthcare are situations.
When we can't use default. So if you can use default great,
you should do that because it's going to work and we have You
have other examples around that the areas where we can't use, it
are a couple of things, you know, one is if the guidelines
aren't clear as to what we should be defaulting patients,
into or doctors into are not for some things.
We have very clear guidelines but for other things like you
know, what's the right intravenous fluid to use, in the
ICU, there's debate around that and that continues or when
should a patient get a mammogram, should it be when an
adult in their 40s? Or should it be when their 50s
or somewhere in between their different guidelines?
That have changed multiple times.
So that's One Challenge, when you probably should, it should
be a conversation. It shouldn't be.
So automatic another is when we can't identify that, the
guidelines are clear but we can't identify the patient
clearly with the electronic health record or whatever data
we have. And a good example here is
smoking and lung cancer screening.
There's new methods of screening.
One for lung cancer using CT scan.
There's National guidelines on that.
We don't do a good job, documenting smoking status.
They are you a smoker or not? How many if so, how many years
when did you quit India? Chronic health record, many
Health Systems only document that for ten to twenty percent
of patients and so and we can't default patients into the right,
screening mechanism because we don't have the data to do that.
Another example, the through pops up for me is when there's
the behavior change is really the responsibility of the
patient that we don't have the ability to to default, there's
nothing to default, right? It requires the patient to do
something. We need to look towards other
other forms of motivation. That's totally right.
And I think that applies it certainly transactional
Behavior. Like you can't default someone
to get a flu shot, you could certainly default them to an
appointment for the flu shot and that that has been shown to help
but the continuous behaviors like exercise, eat.
Well, you can't default people to not eat dessert or to go to
the gym every day and so that's going to require a different
type of intervention. Yeah, I'm curious a quick
question, but when it comes Default versus kind of like,
prompted choice or like an active choice.
Where you have someone maybe in the case of what you mentioned
it when prescribing certain way? And you want to kind of maintain
for whatever reason, maybe that doesn't apply to the first
example, but for whatever reason, you kind of want to
maintain a little more ability to make a decision, but you
still want to kind of maybe get them away from this traditional
approach. For the most part in providing
more of an Active choice to provide from are very conscious
decision. Perhaps that is sometimes being
kind of recommended as an alternative to defaults when
defaults could be little more risk of being unethical.
For example, have you had a personal experience without or
seeing like, how effective that is in comparison to defaults,
for example? Yeah, acting trick is a great
tool to use when you can't do defaults their various different
reasons. I think there's pros and cons,
active Choice. The biggest con is just alert
fatigue. You know, for clinicians in the
electronic health record for patients, whether Text message
our notification. I mean, I can't tell you how
many notifications I get on my phone, even if I try to turn
them off and and I want to pay attention to all of them, but,
you know, I'm going to miss a couple of just, it's just so
many that come out and clinicians.
The risk is they'll just start dismissing all of the alerts in
the electronic health record. The good with the bad.
So if you can design a notification, well, so it
provides additional information. But we all, we often say, the
best types of active Choice, prompt of the ones that don't
just remind you, but they also facilitate.
So, for example, we did a trial. Where we were trying to nudge
doctors to order statins for patients, that have high
cholesterol or high risk of heart disease, then save lives
30 percent reduction in mortality, and so on and so
forth. Evidence-based, we didn't just
say, hey, the patient's do first at inconsiderate.
We said, if patients do for a Statin and we provided options
with the tour or receive a Statin, the generic versions.
Of course, as we talked about and we pre-selected one, we made
it a 90-day prescription instead of a 30-day.
So the patient won't have to refill every month and they
could. All of that work takes a couple
of That's for the doctor and we made it one click.
So you can say except or cancel and that study is in presses and
out yet. But you know, we've had other
studies where we've done that for colon cancer, screening flu
shots and breast cancer screening and had about a 20
percentage Point increase for cancer, screening 50, 60 percent
to 70, 80 percent for vaccination, it's worked as
well. And we test that in a couple of
practices and was rolled out. But the one thing we learned
when we implemented that as we started by Alerting clip,
doctors when they were in the room with the patient and we
shifted to alerting the medical assistant, the medical assistant
gets the patient from the waiting room.
They take their blood pressure, their weight, and then they also
ask the patient a couple questions and we train the
practices, basically train them to accept all of the alerts and
notify the patient. Hey, you're due for breast
cancer, screening, I've gone ahead and place an order in
there. You can talk to your doctor.
If you have any questions or if you don't want it, they can
remove it. But basically it facilitates for
the physician. Do most, but it Prime's the
patient is as the patient. When you walk into the room with
your doctor, you've got a list of what you want to talk about.
I've got back pain and I need a refill of this medication.
Whatever else might be, you know, thinking about preventive,
screening. But if we can use this active
choices and mechanism to Prime the patient right before they
see their doctor, they're not going to be much more amenable
to getting that treatment or test.
I love about that's really wonderful.
And let's see what we can do. In terms of also, what we talked
about when may be active choice of defaults are not enough,
Because one of the themes for this season, the podcast is,
were trying to get even more practical.
We're trying to get really just thinking about how we can, you
know, change the world for better using Behavioral Science.
And so we're going to try to dive into one product or service
or kind of scenario for guests here.
And so for you the the case study, we're trying to look into
here is Jim's. And the idea is obviously, that
you'll be great, if people were more likely to exercise and take
care of their cardiovascular health, and so on.
But, you know, how, how do, how would you change a gym to
encourage people to spend more time there or encourage them to
go more regularly, for example? Yeah, that's a great question.
I mean, the concept of Jim has changed a lot, you know, close
to covid. You know, used to be used to
think a lot about like, going to gyms and then, Now, people's
homes have become gyms and we were, you know, in terms of Y,
then you do see a Resurgence of people going back.
I guess a couple of things come to mind.
One is you know improving access and reducing friction to going
to the gym some through the location of the gym.
Like if it's in your home that the least amount of friction but
certainly that's close by something impossible.
We've seen some organizations or large tech companies put gyms on
their workplace. They also seem like financial
institutions that, you know, I live in Philadelphia and I walk
back up all these big plans. So, you'll see Jim's on the
first floor with people running. So you can go for a workout
right before or right after actually where I worked at hand,
you know, you're to go there was one of the professor's headache
and a shower built into the into the hallway where offices were
and so you could take a shower when you came in.
So it's kind of like promoted the idea that you could go for a
run, maybe run to work even and then get a gym.
So access to that or making it really easy.
Is obviously a key. Factor a colleague of mine,
Katie milk went in, a lot of work with temptation bundling
and so like, you know, making it making there, something else
we're awarding. Now, you can do that on your own
by bringing your phone and helping you, but a podcast,
maybe it's this podcast or something or show or something
else. But Jim's can also do that with
TVs or other things. And now you see these treadmills
that have their own personalized TVs.
It used to be a big two TVs up on top with like 20 treadmills
and now he's treadmill has their own TV and some of you only let
yourself watch your certain show or Or with different podcast
when you're when you're running and the gym potentially know
what your shirt you're so just turn off as soon as you start as
soon as you stop like yeah they could be have to run.
It's also good because these days there's so many different,
you know, streaming services. So the gyms can like you know,
be that place you like you don't you don't have to subscribe to
53 meters as you just go to our gym.
Yeah, yeah exactly. And say of the, you know, like
when you're generating electricity Bike by writing the
bicycle, it's like you can only watch the television show if
you're actively, you're turning. Yeah, if they have that could
work but I got the see how that could backfire frustrated by the
technology but you know a couple other things come to mind.
You seen some gyms add other kind of things that they would
think about pre and post-workout.
So, like a Smoothie Bar power, you know, protein shakes and
things like that to help supplement people in some gyms
with like, These like Aqua massage chairs, and things like
that, that you're thinking about what would people want before or
after and then I think one of the bigger things is like these
social elements. Whether it's a class that you
might do with people, you don't know.
But you have an instructor or it's something that you might go
with someone you do anything that could facilitate you doing
that with a friend or a buddy with more likely to hold you
accountable. You know, you feel like you feel
like you're tired one day but you're signed up to go to a
class with a friend. You might still go because you
don't let that person down. I'm kind of there for that
person. I think that's probably the
strongest, facilitator, and so being a way to integrate that
with Jim's. How might yeah, like getting
really practical? How might a gym actually
facilitate those kinds of social connections, I think right now,
these things are really left to gym members, right to do on
their own. Other than saying, okay we're
going to have this class and there will be people here if you
were the gym Mogul, what might you do?
Yeah, one thing that I would do is Let's say I'm going to give
you an example here, just for discussions sake.
Let's say you've got a class that can fit 30 people, you
know, and you might what you might do is for the first you
know 10 people or whatever that sign up, you might give them a
pass that they can send to one person that has to sign up in
the next let's say three days and if they don't use it in
three days that pass goes away. So they're basically holding
spots for those people that are your friends and family members
or they're willing to overbook the class by a couple of people.
You know, not many are they after some time they could
probably figure out the math. Give away 10, you know, friend
passes. How many actually come in so
that they know how many spots the hold and so on and so forth.
Boy, it does a couple of things for the person.
It makes them feel like they have something that they can
lose and it's a free pass. Many might not even have to be
free. They could maybe only the first
ones free but it's like a spot basically.
They could lose its kind of deadlines associated with it so
you could act on it pretty soon otherwise you know the questions
going to fill up. And then for the gym, it might
be introducing more people to that gym that otherwise wouldn't
have gone there and make Then continue to go there if they
start doing this class together. So anything that makes it easy
for you to book a class with someone else that you know, I
think would be really helpful in facilitating that.
Now if you look at like something that you're using at
home, they allow you to do that. Virtually sign up for a thing
and then defend it to your friend.
Who's following you. It's really seamless the
challenge with Jim's is like it's the physical world.
You've got to get someone to go somewhere setup setup time and
we need to plan for that but I don't see a lot of that being
done. It's like you said, just
basically like Got to do that work on your own.
Find a friend, get them to sign up, send them the link, tell
them which Jim all that people Gables.
I wish learning path. Yeah, one tap, you should be
able to share a link to someone and say, hey this expires in
three days, click here to sign up for.
I already signed you up for this class.
You have to now have something better.
Yeah. Right.
And I'm not getting my money back.
Another thing that Winston to hear your thoughts on is study
of personalizing. The gym experience.
So kind of how do we take advantage of individual
differences across people? You know, contextual
information, time-based differences and so on, is there
something you would change there?
In the gym scenario still? Yeah, in addition, I think
there's a couple of things that you could play with.
I mean one is like the, you know, the communications around
going to the gym and maybe, you know, assuming you've got
something to try to motivate. People haven't been to the gym
in a while. You could personalize that
messaging, you know, based on their either past history.
Like we see it's been 12 days since you've been to the gym,
come back and you know, Beauvoir whatever the motivational
messages. Once you're in the gym, you
could design all kinds of things around how to personalize their
routine. You know, again, the Peter has
to give you information, but let's say you're doing.
You're going to lift weights for your like back and chest and
then you're going to go for a run.
You might offer. Here's a routine that many of
our members use and then show a map around the gym, you know,
where the different, you know, things are that might help them
to discover new opportunities or there might be a class that
relates to something that they're working on.
And then, of course, there's like host Jim messaging.
If you're able to track metrics, maybe it's the person's
blogging. What they did, giving them
feedback on how long they were at the gym.
Jim, what they accomplished. So and so forth that requires
kind of almost like a reporting tracking and communication
system, but another jet lot of gyms have that in place.
But that's how are you. Yeah.
All right, one last gym, really good question.
So you have run a lot of experiments.
I think most gyms to not. With a few exceptions, most gyms
are not experts at running experiments.
But say, you could run one experiment to better understand
your gym members get them to get the most benefit out of your
gym. What what would you do and you
could do anything. That's a good question.
No limitations in terms of resources or yeah, I guess what
I would say, what I would do is try to, you know, thinking of
the model that I described you've got, you know, good
Communications to get people to go to the gym, you've got things
at the gym and then you have things after you leave the gym
to hope that they appreciated what they did.
And then they come back, I would test Communications or
interventions across those different time points and
combinations or have been to see what's the best.
Best timing. I think a lot of people focus on
getting you to the gym. You know, let's send you an
email or a text message or whatever it is to get you to go
to the gym and then we assume, okay, they went to the gym.
That's great. They did their work but
obviously like the workouts can vary but I think it's it's a
broader than that. Once you go to the gym you need
that, you might need that reinforcement after you leave.
And so I would run, you know, many different interventions of
communications before during. And after gym visits to try to
see what Timing and interventions where the most
effective to get people to build a habit of going to the gym at
their number of times a week. And is there a particular kind
of intervention that you would want to test their in terms of
the flavor of that messaging? Yeah, I think a good question.
I would probably use something that were mostly focused on
nudges. They're not incentives.
It's more scalable because, you know, paternity test incentives,
a long nap but then them, you know, figuring out how you would
scale. That might be more challenging,
but I don't know if II have a, you know, approach in mind, it
might be, you know, we might crowdsource different things and
run when I like the mega studies that colleagues have run around
testing different, approaches head to head, but I think either
texting, or if there's an app for the gym than using a
notifications, would be that to us did I?
Can I pitch an idea and see what you think of it?
Yeah. So okay.
I'm on the Bears. One of the writers I think is,
you know, people feeling like they look stupid and the Right
because they don't know what to wear and we talked a little bit
about this idea of you know, social support and so on.
And what if you know you have a gym chain that provides people
with kind of good-looking clothes but also like kind of a
unique like they kind of little bit stand stand out in a way and
so you can have everyone is given the same kind of
comfortable the like pretty good nice looking but also little bit
like weird maybe like some strange color or something like
this, just makes it stand out. Out to everyone who joins the
gym. What you think about this?
This clothing line I like the idea.
I wonder if it would dive more with people that had certain
phenotypes like if you were more extroverted and introverted and
things like that. But I like, you know, you both a
couple aspects into that, so it sounds like it's fun, you know,
it's something different, it's engaging, you know, there's a
lot of work on that and gamification and things around
there. But this is a very subtle way of
like making it a bit more fun. It sounds like it's building a
community because you're finding someone, that's Maybe has the
same you know color shirt you think of like Orange Theory
Fitness or something like that. There's like a color that goes
with or you know both like oh whatever it is.
You feel like you recognize someone as a part of your gym or
Community because of that and that can be important.
And it's also an element of almost like surprise, like you
go there and you're going to see what maybe someones got
something different or your, it's part of the Delight of
going to the gym because you can see what what silly or not the
silly out that people are wearing.
That's really nice. I have a different version of
this. You tweak the mirrors so that
when people are running, they they don't actually see
themselves in the reflection, they see like their own, their
favorite celebrity. So what I'm reading, it's not
awkward Ali and it's like trying to stay on the treadmill.
It's you know it's JLo or whoever is cool now, I think
she's Yeah. Well this is great and I think
we can probably build on some of this as, you know, first of all,
I think this is open for any gym owner to take some inspiration
here but also, you know, moving us along.
I think one topic will be interesting to explore with, you
is gamification and I think it's interesting because I've also
been working with immigration for a while, and I think I think
there's two views of what can the occasion is.
Where one is a very much, this simplified strawman view of
gamification, can a thinking that okay, gamification?
Is you having a problem and then you throw leaderboard, streaks,
progress, bars, whatever at the problem.
And then there is maybe perhaps a steel man version about like a
little more thoughtful. A addition of other
gamification, but I'm curious to hear what is your Explanation of
what good gamification is like what is that Steel Man of
gamification? Look like is it just throwing on
some some of these tricks and bells and whistles?
Or how do you think about good unification?
Yeah, I think you see a question.
I think there's many different elements of gamification has
basic. You know foundations it's using
game-based elements to try to make things more fun and
engaging. I think there have been things
like Pokemon go or you know dance dance, whatever.
It's called being a revolutionary Revolution, your
exercise games that get that get you to exercise.
And for people that those work for, they can be very fun and
engaging, I think the challenge when we We approach this filled
with to say that not many people that could benefit the most from
changing Behavior or participating in, those types of
games are willing to like open an app or have the resources to
buy a gaming system. And so, we wanted to create
something that didn't actually make require you to play the
game to like actively play, like the game runs itself.
You're basically pushed messaging, and you're told
you're entered into a game you're pushing to messaging
because that would get the people who are least likely to
participate to participate. If there's actually no work to
participate, you just To strive for whatever you were doing.
In our case, tested it for weight loss, physical activity
and other behaviors. If you're trying to get your
step count, it's one thing to try to get yourself counts with
nothing. You have to play a game and then
figure out which, you know, Monster you're battling against
or which, you know, special power you're doing.
And so we focused a lot on basic elements and I think this is
really important because we see gamification used in two major
areas that reach populations. One is in digital help app.
We did a study looking at the top 50 app and the Apple health
stores is like 5 years ago and two thirds of them, use
gamification. And then we also see many most
employers or workplace wellness program use gamification in some
way but those both of those get little engagement compared to
what they could have because it requires people to download app
connect to platform. Open the apps every day, log
your steps manually, things of that.
So we want to remove all of the friction and just harness the
core elements of gamification. The addition of behavioural,
insights and social incentives. Those are the two things we were
looking to add to gamification that.
We thought missing, in addition, to, in addition, to Too Much
friction. Most of them are traditional
economic based and and some of them use social invented, some
of them, don't I always struggle with when when people talk about
gamification because it's this whole bucket of strategies and I
you know it's hard to know which ones are they actually using?
And you know what's the relative efficacy of different
strategies? You know you see a lot of people
are using gamification Education.
Are they using it? Well, how how, how are we doing?
Yes. And when we looked, when we do
that for any of the apps, we look to see what were the
elements of gamification that were used in the apps.
Most people think about points and levels and badges, and we
found is, like, actually most of them used the most common
elements of gamification used for things around social
support. So, competition, collaboration,
and support some use Badges and in game elements, and so on, and
so forth. Well, that was one of the things
that made us think about. Okay, how do we make this?
How do we harness our inner? You know, competition
collaboration supporter, inner social incentives to those are
relationships that we might have with our family members, our
friends, our co-workers that are long-lasting.
And so when we turn the game off messaging off your still you
still interacting with other people and so if we can harness
those social incentives, we might create something that's
more sustainable than let's say, a financial incentive.
So we focus on a couple of basic things points and levels but
then we really try to focus on how do we Embed, the behavioral
insights and add in the social incentives, mice.
And what do you have you seen in an examples of things
backfiring? When some of these things been
added and any context things. But in particular, if that's the
case, where you see like a high risk of some of these elements
leading to may be unintended consequences.
I think in some of the early studies that we did, there are a
couple of things that stood out. We had initially four levels to
the game. It was what was it platinum,
gold silver. Bronze.
And what we found is, that people either went all the way
up to platinum, right away. You know, you can move up a
level once a week where they just stayed in bronze.
And so we realize two things, one we need to make more levels.
So if you're like really on debated and you could get so
there's more progression because once you get to the top you get
a little bit bored. So in future studies, we added a
couple more levels. The other with we and the bigger
problem was how do we get people to engage in the first place?
Because if you don't move, if you don't engage in that first
week or two, we probably lost you for the Hole 6 months or 1,
year, study, or whatever? And so we started doing that
work really well, was we made five levels and we put people in
the middle. We have blue bronze, silver,
gold, and platinum. Instead of starting everybody at
the bottom at Blue, we started everybody at Silver and this did
two things for people that were, you know, we were trying to kick
into gear that may not have otherwise been engaged.
It made them feel like they had some endowed status already that
they could lose. So if you didn't engage in the
first week you would move from Silver to Brawn but you That
loss and social status and we make it really Salient to you.
We text you a picture of that you see it on your dashboard,
all of that stuff. The second is that it made the
hit, made the journey not being so hard to start with.
So, if you think about, you know, you're running a race.
You're looking at the person in front of you, you're not looking
at the person that's in, you know, miles ahead of you.
And if you do, you're probably gonna stop running shoe to drop
out of the race. And so we wanted to try to embed
that with in here, a little bit by thing, or you're still very
only two steps away from Platinum.
It makes it seem more achievable to people.
Do you ever see a backfire like are there people who are just so
averse to the points in the levels, that just, you know,
like, see all of these metrics and law, like they can't, they
can't do it. And then they, you know, they're
not going to participate just, just because of that.
Or, or what do you, what's your, are there differences in how
people are accepting of gamification?
Yes, I think, you know, not, not are, there's no one intervention
that's going to work for everyone.
So, The some people will this will not be for you.
I think in our trials and we were in a 10 or 15 of these
large trials at very high risk. Patients patients that had heart
attacks had diabetes or uncontrolled had Strokes.
Just delivered, a baby. All kinds of different stages of
Life, the average dropout rate was less than 3% and I'm across
all of the studies and we had no study that had more than five
percent. So very few people dropped out.
Now what does it mean to drop out to drop out?
It means you've got to contact the study either by email.
Mail or text message or phone call and say hey I'm not
interested in participating, talk to messaging.
Yeah but if you think about it it's really easy to continue
participating because you don't have to do anything.
We send you a text message every day.
One one text message today and it tells you congrats, you reach
your goal yesterday. You still have so many points,
keep it up, and we randomize the messaging, so it's not the
robotic. So it's really easy for people
to stay in the game. I think where we, where we
initially in the in the early stages.
Got law, got lost with some people are more people, was if
they Understand the game, you know, we gave people 70 points
and preach a the week we gave it to them on Monday.
We used to start people on any day and we were like we should
talk people on Monday because it thinks with their weeks and so
we're slowly making changes. But then we started explaining
that we, where we used to do is we send them a long email, which
would have liked for paragraph explaining each part of the
game. We used to have like these, you
could call on, you could forgiveness things.
You could call a friend from your circle or whatever and they
substitute was too confusing. So we decided what we Would send
you a shorter version and then we would walk you through the
game. So every day, we'd explain, hey,
it's day 1, your goal, you're starting off with 70 points,
your goal is to achieve your step count.
Now it's day two. Great job.
You met your goal or sorry, you didn't meet your goal.
We would kind of walk people through and we found that that
explanation as you go, work much better because they're willing
to read like a two-sentence, text message.
They're not going to read that page long email, no matter what
you do and so that was a better. No one's going to read the page
long. Awesome, Talk really briefly
about what you're doing because you're up to some really
exciting things now and, you know, we talked about behavioral
design in the wild earlier. I'm curious, you know, what can
you tell us about your experience doing applied
Behavioral, Science and health care itself?
You know, like really out in the real world.
What is it like? Yeah, I can say, there's lots
and lots of opportunities that being said, it is really
challenging to get people to apply this in the real world.
I think there are a couple of big things.
Themes that come up. We're often looking to test
approaches compared to other things and you know, where we
live in a culture within Health Systems and ensures and other
organizations where a lot of times, we're implementing new
things and rolling them out and then they're moving on to the
next thing on the list because there's so many things we want
to do. And there's not a cycle of
testing and learning that we can apply there.
And so, getting that structure in place is often a culture
change for organizations, but something that many of the
organization's, I've worked on, have really embraced, and it's
allowed me to be able to do Up there but we're looking to
translate more broadly. The second is the clinicians
that spent over a decade training.
A lot of our, interventions are targeted to clinicians and they
gone through residency and fellowship and they're experts
in their field. And so they often are averse to
someone else coming in and helping design, things that
influence them or their patients when they're not from the same
field. And so, the way we get it, the
way, we have a dress, that is two one reveal to them.
You're already being a judge, is not like, we're introducing
something new, whatever the system you're in.
In for the design of your EHR your patient Communications.
There's a notch there, you just often don't recognize it that is
eye-opening them. Those extra steps you need to
prescribe your generic or whatever it might be probably
getting in the way we can help you.
And then two is to is to flip the script as opposed to us
saying, hey we want to help you do this.
We would do crowdsourcing campaigns so that the clinicians
are the patients and the Frontline members would come to
us and say we need help to increase cancer screening.
And now we've got the clinician saying, hey, this is something
we're working on, we could use your help, that's something.
Probably would have warned worked on as well, but it works
better if it comes from them. And then scaling, the
interventions is probably the third kind of thing.
Uh, our interventions are much easier to scale than others.
If you have a, if these are witches are places because once
you turn it on and then there and it can be expanded how many
text based intervention can be that way things that we require
or manual effort or resources that obviously less scalable.
And then there's such variation in some Health Systems compared
to others that you have to make changes.
Changes to fit within the culture of the context of the
work flow. So, I say scaling interventions
is another area, whether it's opportunity.
Awesome, we have a very fun segment coming up.
So we call this game. Matt will it replicates?
And is really just kind of a thought, experiment to make some
Concepts concrete. Okay, So, first hypothetical
people who invite a friend to their annual checkup, or more
likely to attempt, I think it would not, replicate and leftist
and left. The friend was a family member.
All right, place prescriptions get patients, to floss more
regularly compared to dentist recommendations I think that
could work well people really trust the doctor and I think of
a prescription is more concrete than just what's often a verbal
recommendation times leaderboards.
Facilitate me? Kitchen adherence among people
who are high in neuroticism but backfire in people who are high
in extraversion, I think leaderboard I think would not
replicate. I think later book leaderboards,
in many settings are hard to make work well because the
person in first place is often running away from everyone else
and like a more social norming intervention, might work better.
Regardless of someone's personality type companies that
claim to nudge consumers toward better be Xavier are perceived
as more paternalistic than those claiming to quote unquote
designed for Behavior change. I think that I would agree with
that phone. I could see that replicating.
Okay, final one piano staircases and Office Buildings lead to an
increase in the use of stairs in favor of taking the elevator.
If you are comparing a regular their cases, I think.
Yeah, I like unit are cases would be more effective at long
term as well. Sorry, that was my bias, Frank.
I'm curious to long-term know if they may be for small, maybe not
an average. But for small percentage of the
population, you want to make prediction for, like, what is
their phenotype of like, what is their personality traits?
That makes them more likely to enjoy that.
Maybe they are. They're more likely to I see you
the benefit of the design of the staircase or the probably more
motivated at Baseline and they're looking to change their
behavior. Well done, that was those will
very well done. All right.
We test. We have one final question for
you. And this one is a, this is a
tough one. So, take your time with it.
What is your most controversial opinion, in Behavioral Science,
my most controversial opinion, in Behavioral Science?
I guess the one that I've been trying to put out there more
recently given that shifted. My focus has been, I think a lot
of effort in Behavioral Science are on testing different
approaches. And I'm, you know, I was a
behavior. I was an Analysts and the
clinical trial list and so testing record of my heart.
But I think we're a decade in now and I think what needs more
effort or attention is the implementation at the applied
Behavioral Science? I would say we should continue
testing even the applied settings, but I think there's
two almost too much focus on testing and not enough focus on
applications into the real world.
And I think a lot of Behavioral scientists are Yeah, of course,
Hollister Lake to randomize and things like that.
And as do I or did I, I think there needs to be a change and
we they mindset that we need to shift the focus and we need to
shift the efforts towards application.
Still testing but much more on applications.
Yeah, I wonder if there's just a fear that the testing will go
away if you don't keep, you know, emphasizing it.
Yeah. I like a chicken-egg problem.
Like if you can get it to be applied and show that it's go
quietly, maybe it shows you that we need to.
There's always room to improve but but if we don't get it to a,
we don't apply it in the real world and look the point of the
testing in the first place. And I think that well, it's
interesting, especially in the applied world.
I think people especially those who don't have a lot of
experience testing. They they really struggle with
how to prioritize, what to test versus, you know what, to just
go ahead and apply. So maybe maybe the world just
needs more meat. I should sue know what to just,
go ahead and apply right, but you almost need to do the
testing in order to understand that.
So yeah, but I do think we have a decade of testing now.
So we, you know, you know, there's been like 30 different
trials and how do you judge people to get the flu shot now,
or cancer, screening or anything.
Now there's going to be other things where you don't have as
much evidence. Not just from my work move but
from other people's work. And so I think I think 10 years
ago we didn't have that in healthcare or health as much but
now there's much more evidence at least That can serve as a
starting point, so people shouldn't be starting from
scratch. This should start by using that
base Foundation - yo, that's really wonderful advice.
And, you know, in general, this was a really wonderful
conversation. I'm really happy to say that
you've Advanced to Diamond League now.
So it's going to thank you for joining the people talking
points. Yeah, golden badge.
Thank you for having me on. This is great discussion.
It? Yeah, it's really fun.
Thank you. Probably time to wrap up another
episode of the behavioral design podcast.
We hope you enjoyed the show. Oh, and I am an AI.
Yeah, welcome to uncanny valley Sam.
And allene told me this is going to be an awesome season, so make
sure to subscribe and help spread the word, maybe share the
podcast with a colleague, or friend.
And if you want to show us some extra love head over to Habit
weekly. We Come & join, our community
Pro members, get access to a wealth of resources in the
chance to interact with leading practitioners.
It's a great way to support the podcast and deepen.
Your understanding of Behavioral design are fantastic.
Show music is Murgatroyd by the wonderful Dave Pizarro and
thanks to the team at Orange wall media.
For the production of this episode for questions or ideas
for future episodes, email podcast at habit weekly.com,
we'd love to hear from you. Thanks again for I'm listening.
See you next time.