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.
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