oo many employers limit their workforce health promotion efforts to a minimal, one-size-fits-all approach. They simply offer incentives for employees to complete health risk appraisals and preventive screenings. To benefit from improved outcomes that spring from being a Healthy Enterprise (see the sidebar “Healthy Enterprises”), organizations must advance their health promotion initiatives by motivating employees to take action to improve their health by losing weight, stopping smoking, eating nutritiously, exercising, becoming better health care consumers and taking other actions. “Choice architecture”1 — a technique from the field of behavioral economics that organizations use to become Healthy Enterprises — frames employees’ health care decisions and presents choices to them in a very deliberate manner.
Although the employer’s desire is to nudge workers toward better decisions, choice architecture preserves individual freedom of choice.2 The effective choice architect recognizes that employees are motivated differently, think differently and are at various stages of readiness for change. It is useful to characterize a workforce into various “behavioral segments” because each segment responds best to specific types and styles of tailored communications.
Differences in Motivation
A key foundation for effective choice architecture is understanding that people are motivated differently. Employees generally fall into one of three groups: (1) intrinsically motivated, those who are generally self-motivating; (2) extrinsically motivated, those who respond predominantly to rewards such as incentives and approval; and (3) disengaged,3 those who will change only when confronted with strong personal intervention.
To effect behavior change, organizations must trigger a person’s emotions.4 Figure 1 below illustrates the emotional triggers and methods organizations can use to capture the attention of the three different types of individuals.
Rational vs. Intuitive Thinking
In addition to being motivated differently, people are not fully rational all of the time. This has profound implications for organizational efforts to change workforce behavior. Logical arguments and appeals to self-interest are not sufficient. Expectancy theory — which says people rationally think through the costs of effort, the link of effort to performance achievement and the likelihood of personally valued rewards being realized — may be a fine model for pay for performance incentive plan design, but it is inadequate for lifestyle behavior change and improved health care consumerism.
People think in different ways with different parts of their brain, alternating between two types of thought:
- Rational thinking Sometimes, people make decisions with great care, taking into account a range of information and logically processing that information.
- Intuitive thinking More often, people make quick judgments based on the limited information in front of them and previous situations they think are analogous. This pattern-based, representative type of thinking is automatic, unconscious, fast and easy.
Normal human thought involves a combination of rational and intuitive thinking. When people perceive that a situation does not fit an expected pattern, the conscious, rational mind springs into action, alters behavior and forces a decision. Several techniques for influencing thinking (as described by Nobel laureate Daniel Kahneman5) are illustrated in Figure 2 below.
When do organizations prefer employees to be slow and analytical or quick and intuitive?
- If employees with unhealthy lifestyles or poor consumer behaviors might be nudged to rethink their choices, communicating in a manner that forces rational thinking is a good strategy.
- If employees are on the right paths toward health and being effective health care consumers, they deserve the cognitive ease associated with intuitive thinking.
Differences in Readiness for Change
The Stages of Change Model6 purports to describe how individuals go about eliminating a problem behavior or acquiring a positive behavior (see Figure 3 below).
Putting it Together: An Integrative Model for Behavior Change
- Intrinsically motivated people demand high-quality resources. Poor resources cheapen their experience.
- Extrinsically motivated people, who may be following a fad or reacting to a financial incentive, demand easy-to-use resources. Otherwise, they give up.
- Disengaged people need personal intervention during all phases of behavior change
Figure 4 integrates motivation, rational vs. intuitive thinking and readiness for change into a model for behavioral messaging and improving workforce engagement. The model characterizes the importance of different types of messaging and framing for different behavioral segments in the workforce.
The differences in workforce engagement techniques are striking:
Improving Choice Architecture
Advisors to wellness programs use sophisticated risk-factor analysis and predictive models to discover workforce health problems. These analyses, however, create a mindset that focuses on problems, which have a negative connotation that often leaks into communication campaign themes. Unintended consequences from negative framing may include employee defensiveness, resistance to change or a self-fulfilling acceptance of failure. This is exemplified by statements or thoughts such as “It’s too difficult to quit smoking and frankly, I enjoy it,” “Don’t tell me how to live my life!” and “My weight loss efforts are a failure. I will always be fat.”
There are many techniques organizations can use to address these issues. Some of the most interesting include:
- Positive Framing in Messaging Positioning choices and messages in a positive manner affirms past positive experiences and instills hope. Compare the following word sets. Which set is more likely to invite employee engagement?
One clinical technique for health promotion, based on a technique called Appreciative Inquiry (AI), focuses on strengths rather than weaknesses. It encourages creativity, involves personal goal setting and begins with simple tasks for immediate action.7 Using AI, a theoretical conversation between a wellness/health coach and an employee would go through the four phases summarized in the following table:
Aligning positive messaging in a workforce communication campaign with positive messaging in a wellness/health coaching program is extremely important to enhancing employee participation and engagement
- Message Repetition and Priming With repetition, a communication campaign conveys consistent messages multiple times, using different media and channels. Priming is a simple, easy concept — the choice architect makes an impression by establishing a familiar pattern that people later recognize during decision-making. The impression is ideally visual, verbal and experiential. It may be subtle, so the conscious, rational mind is oblivious to it. Priming sets a mood, influences how people make decisions, and changes the decisions people make.
- A Vivid, Provocative Communication Style Capturing employee attention on health care matters requires a communication style that employees will remember. Three examples of provocative language follow:
Coupled with an equally striking image, such language creates a dramatic and memorable effect. For example:
- Communities of Interest To effectively engage employees, organizations should recognize and nurture various communities of interest associated with the workplace. These communities are defined by cohorts — by generation, geography, a hobby, a particular health condition or some other characteristic. Communities of interest, which can be formal or informal, exist because people are inherently social and biased toward cooperating within their peer group.
“Anchoring” and “availability cascades” are critically important concepts in working with communities of interest. Anchoring involves influencing beliefs by conveying numerical values that correspond to desired targets. The context in which numbers are presented is very important.8 Compare the following two statements:
If the goal is to influence employees to eat more fruits and vegetables, the key is to anchor their thinking to the higher numbers in the second statement, which is designed to be memorable. It is catchy and contains two rhymes.
An availability cascade is a focused message that travels very quickly from trusted sources and has limited competing views. The message is intellectually appealing and gains credence as it is repeated throughout a social network. It is highly provocative and results in a frenzy of reaction. Social media has tremendous potential for creating availability cascades within different communities of interest. It also has great potential for defeating undesirable cascades. It is critically important to understand these dynamics in managing workforce communications
The Employer's Role
Although wellness vendors, wellness/health coaches, physicians and other entities play an important role in effecting lifestyle change among employees, the employer also plays a key part, that of the “behavioral-change messenger.” Employers spend a great deal of money on health care communications. By using the choice architecture techniques outlined in this article to shape their messages effectively, employers can generate more value for their communications dollars.
Employers should ensure all their health care communications follow these six rules of effective behavioral messaging:
- Establish personal relevance by using familiar references and consistent branding and involving caring leaders, who are admired and liked, from various communities of interest.
- Trigger emotional responses, including hope, fear, excitement, love, greed and caring.
- Define clear choices about health vs. illness and consumerism vs. waste.
- Convey the value of making smart choices that save employees time and money while helping them feel and perform better.
- Ask employees to complete a small, relevant task, such as crumbling up a cigarette, identifying an urgent care center near home or programming their wellness/health coach's number into their phone.
- Guide employees to the best available resources by scheduling an appointment or providing directions and a map.
Organizations need to realize that people in the workforce are motivated differently and think in different ways. Moreover, they are not all at the same stage of readiness to change lifestyle behavior. Taking steps to communicate effectively with all employees will help make the most of the organization’s health care initiatives and improve people’s lives and organizational outcomes. Organizations that use the techniques of choice architecture will be well on their way to becoming Healthy Enterprises.
About the author:
Christopher Goldsmith is a vice president in the Cleveland office of Sibson Consulting. He has specialized expertise in health benefit plans. He can be reached at 216.687.4432 or firstname.lastname@example.org.
1 Choice architecture is a branch of behavioral economics, which was covered in “Beyond Rational Thinking: Using Behavioral Economics to Improve Workforce Health and Organizational Outcomes” in the December 2011 issue of Perspectives.
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2 Richard Thaler and Cass R. Sustein, Nudge: Improving Decisions About Health, Wealth and Happiness,
Yale University Press, 2008
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3 Sickness or injury may temporarily disengage people from work. Chronic poor health or difficult family issues coupled with boredom at the workplace or hostile work environments may result in disengaged employees.
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4 Robert A Olsen, Perceptions of Financial Risk: Axioms and Affect, The ICFAI University Press, 2008
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5 Daniel Kahneman, Thinking Fast and Slow, Farrar, Straus and Giroux, 2011
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6 The Stages of Change Model, also referred to as the Transtheoretical Model, has been applied to a wide variety of unhealthy behaviors. It was created by the psychologists W.F. Prochaska and C.C. DiClemente. Source: Velicer, W.F., Prochaska, J.O., et.al. Transtheoretical Model, Cancer Prevention Research Center
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7 Shirley M. Moore and Jacqueline Charvat, “Promoting Health Behavior Change Using Appreciative Inquiry,” Family & Community Health, Supplement 1 to Volume 30, 2007
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8 Steven G. Aldana, The Culprit & The Cure: Why lifestyle is the culprit behind America’s poor health and how transforming that lifestyle can be the cure, Maple Mountain Press, 2005
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