#FutureReadyHealthcare
Behavior Change Over Knowledge Gain
We are well versed of the need to get our audience to learn new things, and we are dedicated to creating a culture of learning in different and effective ways. But a more fundamental question to ask could be: why is there a need to drive continuous learning? The answer is simple – our audience needs to keep themselves updated with new information. We could take this a step further and ask ourselves "Why do they need to know new information"? The answer is almost always that they need to be able do or think about something differently, which in turn can enable them to change their behavior to drive a different outcome and further the business' needs.
Behavior change is at the heart of every business need. Let's take a simple example – let's assume to drive higher sales, you are focused on training your sales team. You may need to look at the sorts of conversations that your field teams are having with your healthcare professionals (HCPs). You may discover that they could do a better job asking high-value probing questions. You may then engage your training team and conduct an intensive workshop focusing on questioning. Next, you may implement a follow-up coaching guide and feel good about closing the gap. With this training, you have armed your field teams with new information! But does that mean the training effectively changed behaviors in the long term or fulfilled the underlying business need and translated into higher sales? The answer is not always "yes."
In this paper, we will discuss what behavior change is, the science behind it, and how the training we deliver can impact it. We will also understand where conventional methodologies fall short and explore how we can create a more impactful training that is quantifiable and sustainable.
What We Are Doing Today: Conventional Methodologies
As learning professionals, we understand design thinking and have utilized models like ADDIE (Analyze, Design, Develop, Implement, Evaluate) for time immemorial. There is nothing wrong with ADDIE or other design models. Rather, they give us a great framework for analysis and development of training. However, we can look to supplement the way we think about training development by addressing the behavioral component and the business needs rather than just the pre-identified learning gaps.
Think about the last time you created a training; it may have gone something like this:
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Someone informed you of a gap or a need for training. Let's say, it was for a new indication for Drug X and your commercial reps and medical science liaisons (MSLs) needed to be trained.
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You looked to the past to analyze what you had done in similar situations.
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You may have reached out to a few vendors or consultants for new ideas in the marketplace.
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You settled on a thoughtful, instructionally sound approach with inputs from your stakeholders.
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You developed the training program and launched it successfully.
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The measurement method was probably developed using a mix of qualitative (surveys, etc.) and quantitative data (number of learners who completed the training; scores on the certification test; if you had a pre-test and post-test, maybe you had a delta score to show knowledge gain).
However, you may have struggled coming up with the ROI (return on investment) of your training program.
You are probably familiar with the Kirkpatrick method of evaluating training programs:1
In this model, Level 1 – Reactions & Participation and Level 2 – Learning are relatively simple to measure and are probably what your stakeholders are used to receiving to show the value of your training program. However, increasing one's knowledge may not be the most important accomplishment to showcase to your leadership as it does not prove that your intervention changed behaviors and drove a business outcome.
The more important aspects: Level 3 – Behavior Change and Level 4 – Results are much more difficult to measure, especially if you did not start with those metrics in mind and didn't map them out in the beginning.
Learning and Development directly drives the business at the end of the day and ensures that the business is well-equipped to meet their goals. We are not a cost center! You need to be able to provide your sponsors and stakeholders a clear ROI that shows your organization is making (or saving) money because of what you have implemented. Without this, it is next to impossible to get the organization to believe that Learning and Development is anything other than an enabling function. We want to change the thought process from "We train because our people need to know things and because it's a requirement" to "We teach people how to be more effective at their jobs so that we can fulfil business needs and drive profitability."
Behavior Change
The concept of behavior change is not new. We have been talking about wanting to change behaviors for as long as we have been trying to teach people new skills. We have shared the required knowledge and/or have provided all the tools we believe are necessary to adjust the behavior. With this, the learners should be set and well on their way to successfully implementing the new behavior. Yet, in most cases, we have had varied success with getting the unwanted behaviors to change or to see the uplift in the business need.
"Behavior change" is a term behavioral economists and other social scientists use to talk about how we can adjust the way people work, think, and act. Behavioral economists study biases, tendencies, and heuristics that affect the decisions people make. These biases, tendencies, and heuristics are often so engrained or second nature that it can be hard to tease out the real reason we may be struggling with a behavior change, and thus we often struggle to understand what the right intervention may be to remedy the situation.
None of us are truly rational, completely logical people. We all have goals that we struggle to achieve, even though we know what we need to do. Let's consider an example: To lose those 10 pounds, you would make better food choices, go to the gym more, and drink enough water. If we wanted to get the most out of the day, we should wake up early, plan for the day ahead, stick to the plan, and, finally, go to bed on time. However, it is clearly not just logic that has us looking at the scale and remembering our New Years resolution and wondering what became of that resolve. There are preferences, engrained behaviors, and biases of all sorts that are barriers to these sorts of changes. We find it difficult to overcome these rote patterns even with clear goals and all the right tools at our disposal.
Our learners are in similar situations. We give them a new piece of knowledge and expect that they are going to integrate it into their day-to-day tasks and perform better. We assume that when we give them the tools and explain why they should use them – tahdah! – we have the adjusted behavior. We all know that this is not so simple.
Therefore, what is the right approach to create a behavior change? We will delve into more details in the later sections of this paper, but at the highest level, behavioral design requires that we take a 3-tiered approach:2
Steps in Behavior Design 3
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Diagnose and Map
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Design and Ideate
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Implement / Experiment / Adjust
Diagnose and Map
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In this tier, we look at what the current state is and map out every decision and every step that a learner has to take during the process we're looking to adjust. It is imperative that we understand the current state to uncover the barriers to change.
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We add in any data points that we have to clarify our understanding of the process.
Design and Ideate
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Identify and define the biases that exist within each step.
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Define and reduce barriers to adoption.
Implement/Experiment/Adjust
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Here we come up with a new way of doing things. For our purposes, we will look to create a training program that addresses the gaps that exist while also helping the learners add that information into their greater existing schema of understanding.
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Measure and watch closely – we want to understand and map the new behaviors that are being performed. We want to make sure that the new behaviors close the necessary gaps and that they have the desired outcomes from a business perspective.
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Behavior change is both a science and an art – sometimes the interventions we think will work do not go the way we expected. We need to be ready to iterate and adjust our interventions appropriately.
Why Aren't You Eating an Apple?
Surveys aren't always helpful in providing the real data. When you are thinking about behavioral changes, talking to people about behaviors is not always helpful, as there is rarely a logical cognitive reason for the outcome you are seeing.
For example, a large company in LA wanted to encourage their employees to eat healthier. The company gave their employees a survey, and on it, over 60% said they would take an apple if it was offered to them.
And so, to further the goal of encouraging healthy eating, the company put apples out in their cafeteria and no one took them.
The company tried to unpack what was going on. The employees said they would take them; the apples were prominently displayed – there seemed to be no explanation for why the employees were not taking the apples.
Until you looked at the cafeteria set-up: The apples were competing with fries.
The outcome was that the environment was not conducive to the employees making the decision to take an apple.
We should think about this example when we are thinking about how we can change behaviors. It is not enough to give someone the tools, it is important to understand the motivations, the barriers, and be open to iterative approaches/experimentation in order to change behaviors.
TED Talk Reference4
Embedding Change
Maybe your last training was wildly successful and enabled all the behavior changes you were hoping to see. Maybe some of the first-line managers came back raving that their field rides have been so much better since the training. If that is the case, congratulations! With that said, did you measure the changes 6 months later and a year later? Did the changes in behavior you want to see from your learners stick?
Sustaining any change is difficult. With the fast pace of our business, we often stop measuring after a successful training and look to the next program. We see an initial uptick in behavior change after a focused initiative, and we are satisfied. When we take the time to go back and check later, we often see the old patterns re-emerge if they are not sustained and actively managed.
It is very difficult to stop newly learned behaviors from slipping back to less than desirable behaviors if you don't know the why's behind the behavior. Communication campaigns, refresher training, job aids, etc. are all trying to solve this need and they can be great tools. Before you can employ a tool though, you need to understand what is going on every step of the way. Before reaching into your toolbox, make sure you are using the most effective option for the need that you have identified.
Driving Better Results - Implementation
Integrating behavioral design into your training process can be uncomfortable to start, as it is not the way we have historically thought about creating learning.
The first step is identifying the specific behavior you want to change. The more precise articulation of the behavior and the required change, the better chance of success. We want to be able to measure the behavior and the change as closely as possible, so accuracy is important.
In order to better understand the behaviors, it is necessary to map out all behaviors that are involved. Any decision points, actions needing to be taken, and so on should be mapped visually.
Below is an example of a very simple behavioral map for washing your hands. This example is simple but powerful because of the COVID pandemic we are experiencing. Handwashing has been something that the Centers for Disease Control and Prevention (CDC) and other health organizations have always pushed as a method of ensuring we cut back on communicable diseases; but lately, there has been a renewed sense of urgency around the uptake of proper handwashing techniques. We have seen many interventions tried and iterated.
This is for illustrative purposes. We could get far more granular with this example as there are a lot of complexities when we talk about handwashing. This is intentionally simplified for this example.
It is important to be specific and map what is happening, not what you would like to happen during the process. In this example, there is no new step to add – and some people do the whole process correctly; we are just trying to increase the frequency of people following the behavior. For that reason, you are seeing the "proper" behavior laid out.
Ensure that your map is data-driven wherever possible. Try to not rely on surveys or interviews, and collect as much real and accurate data as possible to fill in your map. In our specific example, you do not want to rely on surveys or interviews at all, as people will self-report that they wash their hands far more often than what surveillance shows is accurate.5
Next, think through what potential barriers to the behavior change may exist. These barriers are anything that hamper the behavior we are trying to create. There are hundreds of different types of barriers, and while we do recommend looking into biases in general (they are fascinating!), here are a few that are probably the most salient for our purposes:
Present Bias:
It is the tendency to rather settle for a smaller present reward than to wait for a larger future reward in a trade-off situation.6 This is a classic experiment – when asked if people want something today or something + bonus in a week's time, they almost always take the immediate gratification option. That's because our present selves are most concerned about our present selves – and future self is not something we are as focused on.7
What that means for us is that if it's slightly inconvenient for our present selves, we often don't weigh out the positive impact a behavior might have for our future self as heavily as it may merit.
Salience Bias:
This describes our tendency to focus on items or information that are more noteworthy while ignoring those that do not grab our attention. A good example of this would be that for many people, the benefits of a warm shower are immediate and perceptible, but the water implications and energy costs are much less so. As a result, the salience bias impedes us from focusing on the actions required to protect the environment, like taking a cooler, quicker shower.8
Attention Bias:
This is the tendency to pay attention to some things while simultaneously ignoring others. This impacts not only the things that we perceive in the environment but the decisions that we make based upon our perceptions. For example, someone who is about to buy a blue car and is thinking about that decision may suddenly notice how many blue cars there are – it will be like there's a sudden explosion of blue cars – they will notice them on TV, on their way to work, everywhere. Of course, the instance of blue cars didn't change, but that person is now "tuned in" to them and so they will stand out more than they did before.9
Cognitive Overload/Choice Bias:
When given more options to choose from, people tend to have a harder time deciding, are less satisfied with their choice, and are more likely to experience regret. This can happen when we are overwhelmed with information or choices. An example of this would be if you walk into an ice cream parlor and have 27 different good options to choose from, you may take quite some time to decide, and then when you are having your ice cream, you may think back to the menu and wonder if you made the right decision. Conversely, if you have only strawberry, vanilla and chocolate as the options, you may make your decision quickly and enjoy your ice cream without a second thought.10
Status Quo Bias:
This happens when people prefer things to stay the same by doing nothing or by sticking with a decision made previously. An example of this bias is health plan enrollment – more often than not, people choose to not move away from their current plan even if they're mildly unhappy with it because it's easier/already in place/the current status quo.11
Intention-Action Gap Bias:
It is also known as the value-action gap or knowledge-attitudes-practice gap. It occurs when one's values, attitudes, or intentions don't match their actions. A good example of this is that you may have set a goal to eat healthy this week but find yourself mindlessly eating chips while watching TV at night. You intended to eat healthy, but what you are doing in reality does not align with that intention.12
Let's return to our example regarding handwashing. Here we are overlaying some barriers that may exist at every step of the handwashing process.13
How can we overcome these barriers? This is where your design thinking and willingness to iterate comes in.
Throughout this pandemic, you have no doubt seen several ways that people and organizations have tried to manage these barriers.13
After you think through the barriers and their solutions, you want to monitor and adjust often.
Iteration is important because you cannot assume that you've fixed a barrier just because it cognitively makes sense that it has been adjusted or removed. Think about the example of the apples displayed for employees – putting the apples out seemed to be the right solution, but until you monitor and adjust, you cannot be sure you are addressing the actual barrier.
Here are some examples of the questions you may ask yourself, the initial barrier identified, the more granular barrier identified, and then the potential solutions to those barriers.4 Think through how these questions are salient to you in your position as a learning professional? Do the solutions ring true to you?
| Question | Main Barrier | Get Even More Specific | Solution Options |
|---|---|---|---|
| Do people remember it? | Attention | Availability Bias | Use reminders |
| Do people see it? | Attention | Saliency Bias | Make it salient |
| Do people want to see it? | Attention | Information Avoidance | Use deadlines and scarcity |
| Is the best option clear? | Cognitive Overload | Choice Overload | Use social proof, defaults, and relativity and simplify |
| Do people lack time/energy? | Cognitive Overload | Scarcity/Depletion | Simplify the ask and increase the benefits of doing it today |
| Do people lack the confidence to make a decision now? | Cognitive Overload | Procrastination/Decision Paralysis | Make the ask feel easier, reduce or streamline choice, and use social norms |
| Do people receive an immediate, concrete benefit? | Present Bias | Present Bias | Add immediate/concrete rewards, social proof, loss aversion, and regret aversion |
| Is there a sense of urgency to act now? | Present Bias | Present Bias | Use deadlines and scarcity |
| Are people motivated, but not following through? | Present Bias | Intention-Action Gap and Self-Control | Use pre-commitment implementation intentions |
| Do people realize the opportunity cost of staying in the status quo? | Status quo | Opportunity Cost Neglect | Make opportunity cost salient and use choice framing |
| Are there potential losses from moving away from the status quo? | Status quo | Loss Aversion, Regret Aversion, and Sunk Costs | Make the alternative more appealing and use financial incentives |
| Is it easy for people to switch? | Status quo | Cognitive Overload | Reduce switching costs |
| Do people see what the majority of others are doing? | Social Norms | Social Proof | Use majority, wisdom of crowds |
| Does the behavior of others signal what is socially acceptable? | Social Norms | Implicit Social Proof | Use messenger effect or reciprocity and recommend defaults |
Earlier we took a very simple example of how learning is developed today. Let's look at the same example but apply our new way of thinking to it.
Let's assume someone comes to you saying there's a need for learning regarding a new indication for Drug X and your representatives and MSLs need to be trained.
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Map the current behaviors. Because it is a new indication, maybe you can map what the representatives and MSLs do today to discuss the product. What behaviors do you want them to add? Will the new indication be relevant to the same or different HCPs they are calling on?
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Understand how the representatives and MSLs are speaking about the product today. You know you'll need to add in plenty of new information – but is there anything that they are doing for Drug X today that they should change with the new indication? Add in data points. How often are they speaking about Drug X and to whom? How often do you want them to speak about the new indication?
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What does success look like? What are the program key performance indicators (KPIs)? Try to get as specific as possible – What are the sales goals? How are they different from the existing product sales goals?
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Put in place the measurement framework – How will you measure the success that you just defined? For sure, you will measure it for Level 1 and Level 2, but how will you measure it for Level 3 and Level 4? How will you report out to your leadership that this training was the root cause of the uptick in sales?
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Create your training based on adult learning principles and with measurement opportunities built in.
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Create opportunities for iterative approaches. Maybe think about a dedicated look-back period 6 months post training. What worked and what did not? What can you adjust to get closer to your KPI goals?
Behavioral design is a more in-depth way of approaching your training. Understanding behaviors and creating training that is geared toward closing behavior gaps and driving the business needs is always going to be worth the extra effort.
Indegene's Approach
Indegene works with clients to understand their business needs first. We work with the organizations to map out current behaviors and the wanted behaviors, and we find innovative solutions to address the gap. We put measurement frameworks in place to show the value of the training and prove out that we closed the intended gap and that the changed behavior drove the intended outcome.
To do that, we have taken a more consultative approach to the way we interact with our clients. Historically, there has been a consulting arm to Indegene and an execution arm – and while those are still in place, we have tied them more closely so that execution works hand in hand with consulting. Often, vendors find themselves hocking widgets or solutions that have worked for clients. Very often, those solutions will have value for most clients. The key though is that sometimes when you have a hammer, everything looks like a nail.
Indegene is taking a step back and wants to look at the whole picture with you and then work with you to create or offer the correct solution or tool for the identified need. This approach, while less flashy, increases efficiency and brings more value to our clients.
References
1.
The New World Kirkpatrick Model. Kirkpatrick Partners. Accessed August 25, 2021. https://www.kirkpatrickpartners.com/OurPhilosophy/The-New-World-Kirkpatrick-Model
2.
Behavioral design. Irrational Labs. Accessed August 25, 2021. https://irrationallabs.com/content/uploads/2020/05/IL-BehavioralDesign.pdf
3.
Fogg BJ. What is behavior design? Behavior Design. Accessed August 25, 2021. https://behaviordesign.info/
4.
Don't listen to your customers - do this instead. Kristen Berman TEDxBerlin. Vimeo. Accessed August 25, 2021. https://vimeo.com/441781345
5.
Freeman M, Stocks M, Cumming O. Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. PubMed. Accessed August 25, 2021. https://pubmed.ncbi.nlm.nih.gov/24889816/
6.
Green L, Fry A, Myerson J. Discounting of delayed rewards: a life-span comparison. Massachusetts Institute of Technology. Accessed August 25, 2021. https://web.mit.edu/curhan/www/docs/Articles/biases/5_Psychological_Science_33_%28Green%29.pdf
7.
Mani L. Hyperbolic discounting: why you make terrible life choices. Nir and Far. Accessed August 25, 2021. https://www.nirandfar.com/hyperbolic-discounting-why-you-make-terrible-life-choices/
8.
Why do we focus on items or information that are more prominent and ignore those that are not? The Decision Lab. Accessed August 25, 2021. https://thedecisionlab.com/biases/salience-bias/
9.
Cherry K. How the attentional bias influences the decisions we make. Accessed August 25, 2021. https://www.verywellmind.com/whatis-an-attentional-bias-2795027
10.
Example 2 - Cultural differences and choice. The Decision Lab. Accessed August 25, 2021. https://thedecisionlab.com/biases/choice-overload-bias
11.
Kirbris D, Kahneman D, Nebel JM. Status quo bias. Behavioraleconomics.com. Accessed August 25, 2021. https://www.behavioraleconomics.com/resources/mini-encyclopedia-of-be/status-quo-bias/
12.
Intention-action gap. The Decision Lab. Accessed August 25, 2021. https://thedecisionlab.com/reference-guide/psychology/intention-action-gap
13.
Abrams L. Study: 95% of people don't wash their hands 'correctly'. The Atlantic. Accessed August 25, 2021. https://www.theatlantic.com/health/archive/2013/06/study-95-of-people-dont-wash-their-hands-correctly/276720/
Author
Liberty Clearwater
