Why Prochaska Was Wrong
By Bill Sims
GASP!
What???
Forgive me for having second thoughts about Prochaska's Stages of
Change theory. For years, like many, I have felt that the Stages of Change
model was THE definitive approach to changing human behavior. For those
of you who are a little rusty on this topic, the theory states that
any type of human behavior change has 5 stages:
-
Precontemplation-You have the problem but have no intention of changing behavior
-
Contemplation-You recognize the problem and are seriously thinking about a change
-
Preparation-You intend to change behavior but have not consistently done so
-
Action-BAM! You changed your behavior
-
Maintenance-You maintain the behavior change for 6 months or more
The model above has been held as the Holy Grail of wellness intervention for many years. The idea goes that you should only try to move people
from one stage to the next stage....e.g., find all the smokers who are
in Contemplation or Preparation and target your efforts at these, with
the assumption being that it is pointless to change the behavior of
people who are not at Stage 2.
I always wondered what would happen if we took the most die hard smoker
(who is at stage 1 and gave him this proposal:
If you stop smoking we will pay you $1 million for every day you are
smoke free.
If you keep smoking we will strap you to an electric chair and kill
you.
According to the Stages of Change Theory, we would be wasting our time
in this experiment, because the smoker isn't ready to change. The
theory holds that he would forego the daily million dollar payout and keep
smoking until we push the button on the electric chair.
But we all know this isn't the case. Given the choice of immediate
death, and immediate wealth, 90% or more of these Stage 1 people will
change their behavior.
For quite awhile I struggled to make sense of all this, and then I went
to a course by Dr. Aubrey Daniels, in Atlanta, Georgia. For those of
you who really want to gain a new approach to behavior change, you can
attend his workshop, as I did. Or you can just read his book, "Bringing
out the Best in People".
Or, you can watch our workshop on Green Beans & Ice Cream found at
www.billsims.com/webinar.htm and review my presentation in Athens Greece
please or South Africa.
Before I delve into the field of Behavior Analysis, let me mention that
human behavior change has been achieved successfully for years in a
field that sits just one door over from wellness: occupational safety.
Using advanced techniques of behavior analysis and coaching, thousands
of companies have changed employee behavior so as to eliminate unsafe
actions and behaviors which in turn have resulted in elimination of 99%
of all on the job injuries.
So successful have these efforts been that in the last 25 years we have
seen workplace safety improve to the point that you are now 10 times
more likely to be killed going home from work than while you are on the
job.
A. What are the techniques that have helped Safety Managers change human behavior and save millions in the process?
B. Why is the ABC theory more important than Stages of Change in wellness?
C. Why are the most popular kinds of wellness incentives also the least effective?
All of this and more we will now discuss...
a) What are the techniques that have helped Safety Managers change
human behavior and save millions in the process?
Please don't zone out and say "oh, that is for safety, so it isn't
relevant to me". Safety behavior change is a great model to study, since
it has been around much longer than wellness behavior change, and as
such, it has matured fully.
In fact, we can apply the lessons we have learned in 25 years of
developing over 1,000 of these programs to the new challenges of wellness
behavior change.
First off, the ABC model holds that every Behavior has three actual
components.
The ANTECEDENT gets you to see the need for the behavior, then the
BEHAVIOR occurs, and the CONSEQUENCES follow.
For example, when you are hungry (ANTECENDENT) you eat (BEHAVIOR) and
it tastes good (hopefully) and fills you up (CONSEQUENCES).
There are many antecedents around us all the time: stop signs,
billboards, tv ads, etc. and these do a good job of getting a behavior to occur
ONE TIME.
It is the job of the CONSEQUENCES to get us to repeat the behavior a
number of times.
Here is a common wellness problem that demonstrates the ABC process in
action.
You are hungry and so you eat a Krispy Kreme Doughnut. The
consequences that follow immediately (if you are like me) are:
-it tastes great
-it fills you up
-you want more
All of these consequences are POSITIVE, IMMEDIATE, and CERTAIN.
They drive people to eat donut, after donut, after donut.
Now, there are also negative consequences to eating these donuts:
-I might get fat
-I might get diabetes
-I might have a heart attack
These NEGATIVE consequences however, are FUTURE and UNCERTAIN (because
hey, I could get hit by a bus tomorrow and so I don't have to worry
about getting fat).
Now, what you should begin to see is that PICS (positive, immediate,
certain) are the most powerful kinds of consequences to sustain a
behavior whiles NICS (negative, immediate, certain) are the best at stopping a
behavior. However, NICS must be used as a last resort since when we
use them we will lose much of the morale and discretionary effort that we
want our employees to have.
Using the PIC model, it is easy to see why people keep smoking (PICS
keep them doing it while the negative consequences of cancer are
uncertain and future) and why people give up diet and exercise (because there
are plenty of NICS in the early stages of those behavior changes and
almost no PICS)
PICS have been used billions of times to change safety behavior (e.g.
wear your hardhat, lift with your legs not your back) but we are only
beginning to understand their power with wellness change.
Further, we see a vital need to focus on early, upstream behavior
change.
Instead of only rewarding the people who lost 30 pounds (trailing
indicators) we should positive reinforce people the FIRST DAY they change
behavior and order that salad instead of the usual cheeseburger.
Ok, so I think I've pretty much nailed points a) and b) above...now
let's look at
our last question...
c) Why are the most popular kinds of wellness incentives also the least
effective?
Over 75% of all companies using wellness programs have decided to use
an incentive (that's good, cause we need more PICS) but over 80% of
those same companies in our study say that they are not reaching HIGH and
MEDIUM risk employees who drive 70% of their healthcare costs.
Why?
What's wrong with this picture?
There are several problems with the current approaches to wellness
incentives which cause them to be less than successful.
The top 3 most popular incentive choices according to our Welcoa survey
of over 400 firms are:
Cash-25%
Health Insurance discounts-25%
Gift Cards-15%
Tangible reward programs are only 6% of the market. So why are the big
three failing to deliver sustained wellness behavior change?
In fact, recent study by SHPS states conclusively that cash & health
insurance discounts are the most popular incentive choices, and it
concludes that they are most effective. But this conclusion is wrong.
Let's dig deeper into the numbers.
Companies who awarded their employees for wellness participation and
used Health Insurance discount spent $450 per employee per year...OUCH!
And they only got 50% participation. Divide the numbers together and you
will see that you are going to spend $9 per employee per percentage
point of participation.
On the other hand, companies who awarded employees with Cash spend $210
per employee per year and achieved 70% participation. Do the same math
and you will see that cash is a clear winner over healthcare discounts
at a factor of $3 per employee per percentage point of participation.
However, the group of companies who used tangible merchandise drawings
spent a paltry $3 per employee per year and still got 32%
participation...so on a dollar for dollar basis, tangible reinforces produced better
results than cash or healthcare discounts!
Why is this so?
Because Healthcare discounts, while they are positive, are NOT
IMMEDIATE and CERTAIN. You might get hit by the bus before you ever get to cash
in those chips.
Cash is clearly a much better PIC, as is shown by it's results, BUT, we
should factor in 3 studies done by Mazda, Goodyear, and University of
Waterloo.
In the studies, people were asked "what should we give you to reward
you for doing something extra?" such as taking a health survey etc. 82%
of the employees said "Give us the money, honey, cause cash is king."
This typical response is the reason that so many studies such as the
one by SHPS conclude that cash is the most effective motivator.
But the Waterloo study proves that conclusion false. They gave half the
employees $100 cash to complete a survey and the other group received
a tangible reward (e.g. that $100 ipod she always wanted but they were
in debt on their credit cards and the baby needed new shoes).
People who were given a tangible reward worked 3 to 6 times harder than
those who got money, which is usually used to pay down bills.
What can we conclude from this?
If all factors are equal, the use of a tangible and income tax free
reinforcer will provide greater ROI than CASH ever will. In short, if we
spend $210 per person per year on a tangible reinforcer program that
offers IPODS, Trips, and many other tangibles, we will see greater
participation than the cash program where almost half of the budget goes to
income tax, and the remainder becomes a payment on the visa bill.
Last, and perhaps most important, most wellness incentive programs have
become an "entitlement".
In the early 80's we built wellness incentive solutions for the Home
Depot, Bank South, and AT&T.
Following the best advice of the wellness gurus of the day, we would
typically reward people for things like signing up for a walking program.
Usually, we'd give a Tshirt and a Water Bottle.
With few exceptions, the people who signed up were healthy, already
walking 3 times weekly, and were our low risk employees.
We went to the 8th floor where the overweight, chain smoking operators
were and asked them why they didn't sign up for our program to win this
really cool water bottle and t shirt.
They laughed us out the door.
So at the end of the day we didn't get behavior change from anyone.
Our low risk folks were walking already....we just gave them a free t
shirt.
Our medium & high risk folks were telling us that it would take a much
bigger PIC than a t shirt to get them to make all the behavior changes
they would have to make to get healthy.
And not much has changed today. Whether companies use gift cards, FSA
contributions, cash, or t-shirts, they are continuing to reward mostly
their healthy, low risk employees.
What is needed is a strategic approach to incentives that matches the
PICS with the risk. That means that we need a bigger carrot for medium &
high risk folks. And a little something for those who are low risk.
Our research shows that 4 out of 5 wellness programs still fail to get
the medium & high risk people on board. Now I know some will whine when
I say that we should stop giving away the candy store to our healthy
people. But many of these low risk health folks will switch jobs 2 to 4
times till they settle down.
It's time to start viewing our employees as Triage in the ER. We need
to put our money and resources where are medium and high risk folks
are--since they drive 70% of our healthcare costs. We also should
understand that Stages of Change is a good map to have, but the engine of
behavior change is managing the positive consequences effectively for each
person.
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