Social Marketing and Healthy Behavior*

Punam A. Keller

Punam A. Keller is the Charles Henry Jones Third Century Professor of Marketing, Tuck School of Business, Dartmouth College. The author gratefully acknowledges the CVS/Caremark Member Engagement Team, Melissa L. Miner, Director of Health Promotion and Wellness, Dartmouth College, Robert K. McLellen and Karen M. Gollegly from DHMC for enabling the field studies, and Sarah A. Memmi and Allison H. Armstrong for editing assistance. Please send all inquiries to: punam.keller@dartmouth.edu

* Forthcoming in the Handbook of Persuasion and Social Marketing David W. Stewart (ed.), Marketing, New York: Routledge, 2014.

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ENABLE: Efficient-Novel-Active-Behavioral-Levers

Health providers, companies, and governments are using a variety of health promotion

initiatives to improve health outcomes and reduce health costs. Health providers are

experimenting with shared decision-making to incorporate patient-centered goals. Several

companies are using financial incentives to encourage employees to enroll in wellness programs.

As well, government health agencies are ramping up social media efforts to disseminate health

education.

The broad scope of health promotion objectives presents an enormous challenge to basic and

applied disciplines. While public health research has identified important factors that contribute

to successful health behavior change such as access to healthy food, parks, and health care, the

success of these initatives depends on individual participation. Insights on the psychological

processes underlying health-related decisions can reveal how individuals make trade-offs when

choosing between advocated health actions and status quo behaviors. Research in consumer

behavior, behavioral economics, and psychology has the potential to identify new behavioral

levers to encourage individuals to adopt healthy actions.

This chapter makes the case for ENABLE - a new health intervention tool. ENABLE is an

acronym for Efficient-Novel-Active-Behavioral-Levers. ENABLE interventions combine health

communication, marketing, and choice architecture to increase active participation in initiating

healthy behaviors. The ENABLE guidelines can be used with or without financial incentives to

enroll in health programs. Support for ENABLE is obtained in six field studies. Three studies

demonstrate how ENABLE can enhance enrollment in programs that do not offer financial

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incentives. Three additional studies show how ENABLE can increase enrollment in programs

without adding to existing financial incentives.

This chapter is divided into three sections. The first section describes the economic, health,

and legal climate responsible for the growth in corporate wellness programs. The second section

examines the role of financial incentives in enhancing healthy behaviors. Section three contains

an analytic review of research in multiple academic disciplines that were used to inform

ENABLE. The chapter ends with concluding remarks on the benefits of ENABLE and

opportunities for ENABLE extensions in non-enrollment contexts.

Workplace Wellness Programs

Broadly, a workplace wellness program is an employment-based activity or employer

sponsored benefit aimed at promoting health-related behaviors (primary prevention or health

promotion) and disease management (secondary prevention). Wellness programs have become

very common, with 92 percent of employers with 200 or more employees reported offering them

in 2009 (Mattke et al. 2012).

However, a formal and universally accepted definition of a workplace wellness program

has yet to emerge, and employers define and manage their programs differently. It may include a

combination of data collection on employee health risks and population-based strategies paired

with individually focused interventions to reduce those risks. Programs may be part of a group

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health plan or be offered outside of that context; they may range from narrow offerings, such as

free gym memberships, to comprehensive counseling and lifestyle management interventions.

Wellness programs are viewed as instrumental in reducing company health care costs. An

annual survey by PricewaterhouseCoopers' (PwC) Health Research Institute indicates U.S.

employers can expect to see health care costs rise by 6.5 percent in 2014. The PwC survey

shows that 89% of employers will likely increase their health and wellness efforts to offset an

almost certain rise in health costs. Three factors are responsible for the increase: 1) the formation

of ACOs (Accountable Care Organizations) are predicted to reduce competition among providers

and drive up payment rates, 2) Medicare and Medicaid payment rates are expected to decline

relative to private payment rates, and 3) Higher claims for stress-induced illnesses, which are

highly correlated to unhealthy behavior and adverse health conditions such as heart disease.

To manage the increase in health costs, employers are using high deductible health plans to

shift the burden of medical costs to employees through increased cost-sharing. The new plan

designs are making it far less attractive for workers to use the services of physicians and

hospitals that are out of the plan’s network. In some markets, employers are becoming more

selective about which providers are in the network, choosing to exclude high-cost and premier

hospital systems.

The most proactive employers are planning for future scenarios and making incremental

changes now. Their vision is aligned with transformational changes in the way health care is

delivered and paid for, and a more collaborative and integrated model focused on health and

wellness in which the insured bear more responsibility for their own health. Companies use a

variety of methods to encourage employees to become healthier, including health risk appraisals,

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counseling, educational materials, and disease management and weight-loss programs (Keller &

Lehmann, 2009). Survey data indicate that the most frequently targeted behaviors are exercise,

addressed by 63 percent of employers with programs; smoking (60 percent); and weight loss (53

percent). Increasingly, companies provide financial incentives for participation (Haisley et al.,

2012; Linnen et al., 2008). The next section examines the nature and effectiveness of financial

incentives to increase participation in corporate well-being programs.

Financial Health Incentives

The new health care reform law allows companies to increase financial incentives for

employee wellbeing. Existing wellness regulations developed under the Health Insurance

Portability and Accountability Act (HIPAA) permit wellness incentives of up to 20 percent of the

total premium, provided that the program meets certain conditions. The health care reform law

increases the amount of the potential reward/penalty to 30 percent of the premium, with some

leeway for federal agencies to increase that amount after they conduct a study on wellness

programs. In addition, the bill creates a $200 billion, five-year program to provide grants to

certain small employers (fewer than 100 employees) for comprehensive workplace wellness

programs. The grant goes to small employers that did not have a wellness program when the law

was enacted.

A survey of 147 large and mid-sized companies conducted by Fidelity Investments and the

National Business Group on Health found that the amount of wellness incentives is increasing.

The study found that companies offered incentives that averaged $430 per employee in 2010, a 6

40% increase from the $260 per employee offered in 2009. Just as they did in 2011, employers in

2012 plan to spend, on average, 19 percent of each employee's salary on voluntary benefits, and

18 percent on mandatory benefits. Strong incentives include money; time-off from work;

reduced co-pays; and a point system in which points accumulate to greater and greater values for

merchandise, lotteries or reduced health care premiums (Haisley et al., 2012; Linnen et al.,

2008).

Despite the generous rewards, employers remain uncertain regarding the effectiveness of

financial incentives actually work in influencing behavioral changes. Unless employees are

interested in participating in workplace wellness programs, these programs will not be effective

in reducing corporate health care costs. A Rand Health 2010 Report reveals that typically fewer

than 20 percent of eligible employees participate in wellness interventions (Mattke et al., 2012).

A Buck Consultants 2009 report indicates more than half of surveyed employers thought

incentive rewards were moderately effective (33%), minimally effective (24%) and not effective

(4%).

Yet many employers plan on increasing the annual value of the rewards in upcoming years,

according to the survey. "This rise in use despite uncertain results may reflect a belief in the need

to continue to increase the size or value of the incentive and/or experiment with differing

approaches and types of incentives, in order to find the optimal motivational mix," observe

analysts at Buck Consultants. Accordingly companies are actively seeking new ways to enhance

healthy employee lifestyles and reduce direct (cost sharing) and indirect (lower productivity)

costs.

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To sum, the extant evidence on financial incentives indicates they have a role, but they are

costly, and they often are not sufficient to achieve the desired level of participation. The next

section introduces a new tool to increase participation in wellbeing health programs. ENABLE

can be used with or without financial incentives. The evidence on ENABLE indicates it goes

beyond financial incentives to produce measurable, cost-effective results.

Research Support for ENABLE: Efficient-Novel-Active-Behavioral-Levers

ENABLE is based on critical analyses of research on the effects of fear arousal, message

framing, decision-making models, and choice architecture. The findings from these studies form

the theoretical base for the ENABLE tool. ENABLE contains ten features that diverge from

traditional health tools (Figure). The theoretical rational for each ENABLE feature is described

in this section.

-------------------------------------- Insert Figure here

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ENABLE Reduces Fear Arousal and Increases Self-Efficacy

According to conventional practice, individuals are motivated to enroll in corporate health-

related programs if they are afraid of the consequences of being unhealthy. In contrast, ENABLE

encourages employees to enroll by increasing their self-efficacy or confidence in undertaking

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healthy actions. Extant evidence on two popular fear-based models, Health Belief Model (HBM)

and Protection Motivation Theory (PMT) supports the premise that fear can deter health

behavior change, whereas an increase in self-efficacy encourages health undertaking.

Rosentock’s (1974) HBM and Rogers’ (1975) PMT are influential frameworks for explaining

and predicting acceptance of health and medical care recommendations. According to HBM and

PMT, individuals will be more likely to enroll in health programs if they perceive an increase

health threat as well as an increase in their ability to cope with or reduce the health threat.

Medical consequences (e.g., death, disability, and pain) and social consequences (e.g., effects of

the conditions on work, family life, and social relations), increase perceptions of health threat.

When individuals believe that there is a feasible and effective means of removing the

impediments to undertaking the recommended behavior, this increases their motivation and

ability to undertake healthy behaviors.

HBM and PMT recommend health communications that increase perceptions of threat AND

the ability to cope. Unfortunately, most health communications increase threat by arousing fear

without increasing beliefs about coping. Moreover, it is unclear whether fear arousal is

necessary. A recent paper reports the results of a critical re-analyses and extension of previous

meta-analyses on studies using fear appeals (Peters, Ruiter, & Kok 2012). The evidence clearly

indicates that under low efficacy conditions, where there is no information about coping,

threatening information may boomerang and cause people to engage in health-defeating

behavior!

The undermining effects of fear arousal on behavior change are in line with four other meta-

analyses: 1) Albarracin et al. (2005) found “no threat-inducing argument had any positive

behavioral effect whatsoever” (p. 882), and 2) Earl and Albarracin (2007) found that fear is not 9

an effective way to promote HIV-relevant learning or condom use either immediately following

the intervention or further in the future, 3) Keller and Lehmann’s (2008) meta-analysis of health

communications found that fear is not a significant predictor of intentions to adopt a variety of

health behaviors, and 4) Janz and Becker’s (1984) analyses of 34 HBM studies indicate

perceived susceptibility or beliefs about the severity of the consequences of the health behavior

are the least important variables for influencing perceived threat. Instead, perceived barriers to

taking action or the extent to which treatment or preventative measures are perceived as

inconvenient, expensive, unpleasant, painful, or upsetting proved to the most powerful of the

HBM dimensions across various study designs and behaviors.

One reason for lack of health behavior change may be that people are not sufficiently

motivated by a sense of guilt, fear, or regret. Experts who study behavior change agree that long-

lasting goal attainment is most likely when it’s self-motivated and rooted in positive thinking. In

October 2006, the Economic and Social Research Council, a British research group, released

findings on 129 different studies of behavior change strategies. The survey confirmed that the

least effective strategies were those that aroused fear in the person attempting to make a change.

Keller and colleagues identify several reasons why fear arousal does not motivate healthy

behavior change (Block & Keller, 1998; Keller, 1999; Scammon et al., 2010). First, the

perceived probability of the event’s occurrence is lowered as the level of fear arousal is increased

(Block & Keller, 1998). Second, lower values on coping appraisal can reduce threat appraisal. In

other words, people are more likely to accept that they are at risk when they believe they can do

something to reduce the risk. For example, graphic images of health consequences are effective

only when individuals believe they can successfully reduce the threat or when they have high

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self-efficacy (Block & Keller, 1997). Thus, fear arousal does not produce healthy behavior

change when the health message does not also increase coping appraisals.

Along these lines, Keller (1999) indicates that the conventional wisdom for designing fear

appeals - based on higher fear arousal and placing consequences ahead of recommendations - is

more persuasive for those who are already following the advocated recommendations. In contrast

for non-adherents, lowering the level of fear arousal and communicating recommendations

before consequences is more effective because they are more able to follow the

recommendations, and less likely to refute the message claims. To sum, we cannot simply scare

individual employees into action - instead we must empower them to act!

The literature cited above highlights the risks of using fear arousing health materials without

empowering employees to change health behaviors. Of all the antecedents in health behavior

models, self-efficacy has the highest positive correlation with intentions to engage in the

advocated health behaviors. Important insights for ENABLE’s intervention design are obtained

from extant research on fear appeals. To effectively change health behaviors, ENABLE

interventions need to have a low-level of fear arousal and address any barriers that reduce self-

efficacy. The first brief describes an ENABLE application to increase self-efficacy by removing

barriers and lowering fear arousal.

------------------------------------ Insert Brief 1.0 Here

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ENABLE Uses Mixed Frames to Prompt Regret Aversion

Health communications typically use either gain-framed information (how behavior change will

make good things happen or avert bad things) or loss-framed information (how absence of

behavior change will prevent good things from happening or will make bad things happen,

Rothman et al., 2006). In general, most health messages use loss frames. Although it may appear

obvious, reminding people of what they will lose for the non-preferred alternative is persuasive

because we often ignore self-evident information (Schwarz & Hippler, 1991), especially if it

evokes negative emotions like anxiety and regret (Luce, 1998; Schuman & Presser, 1977). And

averting regret by highlighting a missed opportunity to undertake a healthy behavior is an

effective method to create behavior change (Keller et al. 2010).

The framing literature suggests it is worthwhile to consider type of health issue and

individual differences before deciding on the message frame. Rothman et al. (2006) argue the

influence of a given frame on behavior will depend on whether the behavior under consideration

is perceived to reflect a risk averse or risk-seeking course of action. Since detection behaviors

such as biometric screenings are considering risk-seeking - that is the individual may find s/he

has a disease - Rothman et al. (2006) recommend using a loss-framed health message for

detection behaviors. By contrast, a gain-framed message is recommended for preventative

behaviors such as weight loss because such behaviors are construed as promoting risk-aversion.

For example, communication for enrollment in biometric screening would best be accomplished

with a loss-framed appeal (e.g., if you do not get screened you may have a heart attack), whereas

communication for enrollment in an exercise program would benefit from a gain frame (e.g., join

this exercise program to increase your stamina and strength). 12

Individual perception of health risks influence frame effectiveness. The framing literature

indicates one frame does not have an advantage when perceived risk is low: Gain and loss frames

are equally effective when individuals believe the message recommendations such as getting a

mammogram are likely to lead to desirable health outcomes such as no breast cancer (Block &

Keller, 1995). Loss frames are only more effective than gain frames when response efficacy is

low or it is uncertain the health recommendations will lead to the desired outcome (Block &

Keller, 1995; Meyerowitz & Chaiken, 1987; Rothman et al., 1993). For example, either a gain or

loss frame could be used if the audience believes the biometric screening program is efficacious,

whereas a focus on what they will lose is more likely to encourage individuals to consider a less

efficacious weight loss program.

The framing literature identifies two additional individual characteristics for selecting a

health message frame - level of recipient involvement and regulatory focus. The framing

literature recommends gain frames if the message audience exhibits low involvement with their

health (Maherswaran & Meyers-Levy, 1990). Low motivation to process the message often

prevails in health contexts because people in denial about their health problems typically engage

in defensive tendencies to avoid the message (Luce, 1998; Ray & Wilkie, 1970). Negatively

framed messages or loss frames increase motivation to avoid health messages.

Whether the employee is generally motivated by accomplishment (promotion focus) or safety

and security (prevention focus) can also influence the persuasiveness of message frames. In a

meta-analysis of health message effects, Keller and Lehmann (2008) find higher intentions to

follow health recommendations when gain frames were paired with a risk-seeking promotion

focus and loss frames were paired with a risk-averse prevention focus. Tailoring the message

frame might be worth the cost if data on regulatory focus were readily available. Without

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knowledge of the regulatory focus of employees, it will be difficult to match the message frame

to the regulatory focus of employees.

Low involvement with health goals and health action planning presents a big challenge to

select one frame for different types of health issues. For example, Rothman and Salovey (1996)

recommend a loss frame if there is a high probability the outcome from following the

recommended health behavior will be unpleasant. Thus individuals with previous health risk

indicators such as obesity or high blood pressure are predicted to be more persuaded to get a

cholesterol test if it is framed as a loss (if you do not get a cholesterol test, you may have a heart

attack) than a gain (if you get a cholesterol test, you will be able to detect heart problems early).

However, the framing literature recommends using a gain frame since it is highly likely these

individuals will be less involved with their health. The conflicting frame recommendations

increase support for using mixed frames. .

In the absence of data and in light of conflicting theoretical recommendations, a combination

of gain and loss frames are employed as ENABLE behavioral levers. ENABLE interventions are

designed to increase regret the individual may feel for not taking action (e.g., missing a short-

term opportunity to undertake a healthy behavior, Keller et al. 2010). The second brief describes

an ENABLE application with mixed frames to increase regret aversion.

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Insert Brief 2.0 about here ----------------------------------

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ENABLE is Personal and Increases Commitment

Despite the consensus that people may need strategies to shift focus to long-term costs from

short-term costs (Thaler, 1981), most health communication is based on the premise that once

individuals comprehend the message, they will act in their best interest by following the

recommendation to reduce their health risk. By contrast, the behavioral economics literature

indicates most individuals will not opt to follow the health recomendations because they believe

there is no cost if they stick with the status quo behaviors (Batra, Keller, & Strecher, 2011;

Keller et al., 2010). A review of the literature indicates two main communication shortcomings

are responsible for reducing motivation to follow health recommendations: 1) Individuals do not

believe the message is for them and, 2) the message does not enhance commitment to change

behavior. To overcome these shortcomings, ENABLE uses first-person singular (“I”) pronouns

to increase personal relevance and asks each message recipient to make a commitment to

changing his or her behavior.

Beliefs that health risks are not imminent may be necessary coping strategy for individuals to

get through the day. However, these beliefs may become the basis for an optimism bias that

reduces personal relevance and commitment to undertake healthy actions (Weinstein, 1987).

Individuals exhibiting an optimism bias in their decision-making often see themselves as better

than the average person and often hold overly optimistic views of their health future (Folkes &

Kiesler, 1991; Keller et al., 2002; Weinstein, 1987). Optimism bias often results in self-serving

denials (positive self-illusions, rationalizations, excuses, and displacement thoughts) and lower

perceived vulnerability (Block & Keller, 1998). The literature on tailored communication

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described below provides valuable insights on increasing personal relevance to reduce the

optimism bias.

There is substantial evidence that tailoring health messages increases personal relevance,

persuasion, and behavior change. For example, Block and Keller (1997) found a condom

message to tailored by gender (e.g., Women and Safer Sex) was deemed more relevant and more

persuasive than an untailored brochure (e.g., Safer Sex). Three studies provide strong evidence

for the positive effect of message tailoring on health behaviors: 1) Brinberg and Axelson (1990)

found that tailoring health messages significantly increased fiber intake (59%) as compared to an

untailored message (46%), 2) Strecher et al. (1994) found that smoking quit rates were higher

with a tailored than a standard message (30.7% vs. 7.1%), and 3) Marcus et al. (1998) found

more exercise when participants received tailored communication (151minutes/walk versus 98

minutes/walk).

Unfortunately, tailoring poses many challenges to practitioners the biggest of which is

collecting data on relevant ways to segment the audience (Keller & Lehmann, 2008),

Segmentation criteria such as decision-stage (Brinberg & Alexson 1990; Marcus et al., 1998;

Keller, 1999), attributions for past failure (Strecher at al., 1994), prior behavior (Keller, 1999),

prior emotional states (Keller, Lipkus, & Rimer, 2003), and regulatory focus (Keller, 2006) are

difficult to collect due to time, cost, and privacy concerns as per HIPPA regulations. Even when

segmentation data are available, the costs of tailored communication are generally higher as

different creative strategies and methods of dissemination may be necessary to reach distinct

target audiences.

An alternative less costly strategy to increase personal relevance is to increase self-

referencing via the message content. For example, a health message can increase personal 16

relevance by asking message recipients if someone they are close to has had breast cancer. Self-

referencing has been described as a cognitive process whereby individuals associate self-relevant

incoming information with information previously stored in memory (one's self-concept) in order

to give the new information meaning (Bellezza, 1981, 1984; Kuiper & Rogers, 1979; Markus,

1977, 1980; Rogers, 1981; but see Keller & Lehmann 2008; Yalch & Sternthal, 1984).

Individuals who self-reference information are more likely to remember that information and

respond to it in a favorable way. Studies have documented that self-referencing results in more

effective health communications, since they lead to enhanced recall, learning, and memory

(Bellezza, 1981, 1984; Bower & Gilligan, 1979; Keenan, Golding, & Brown, 1992; Kuiper &

Rogers, 1979; Lord, 1980; Rogers et al., 1977).

One of the successful self-referencing strategies is for the experimenter to instruct subjects to

relate the stimulus information to themselves (Bellezza 1984; Lord 1980; Shavitt & Brock, 1984;

Yalch & Sternthal, 1984). For example, Shavitt and Brock (1984) found that when they

instructed subjects to relate an advertisement to their own experiences, subjects in the self-

relevance condition elicited more self-originated thoughts and more thoughts focusing on the self

as target than subjects who were told only to recall the message. First-person sentences

beginning with “I” can also be used to gain access to an individual's self-concept (Rogers, 1974),

or to measure whether the self-concept has been accessed. The use of singular first-person

language in "I"-related statements is commonly used by researchers to measure the extent to

which persons self-reference by analyzing their cognitive responses and the occurrence (Davis &

Brock, 1975; Shavitt & Brock, 1985). Accordingly, ENABLE uses singular first-person language

to increase personal relevance by gaining access to the individual’s self-concept.

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Inability to make a commitment is also a major barrier to enrollment in health programs. The

word commitment is typically accompanied by a statement of purpose or a plan of action.

Commitment is commonly used to make proclamations about the seriousness of a relationship.

Commitment interventions have been shown to be an effective means of increasing recycling

(Bacamotes et al., 2013; Wang & Katzev, 1990), safety belt usage (Geller, 1989), solar

protection to reduce skin cancer (Lombard et al. 1991), weight loss (Black & Sherba, 1983), and

reducing unnecessary medical imaging (Brink & Amis, 2010). The theory behind commitment is

that it has the potential to elicit personal reasons to participate, which may activate intrinsic

motivation, which, in turn, is more likely to cause the desired behavior to continue after the

commitment period is over. Prior research has suggested that written commitment is generally

more successful than verbal commitment (Burn & Oskamp, 1986).

Health communication can be viewed as preachy even though it often does not explicity ask

individuals to take healthy actions. PSAs are viewed as something for the public to know rather

than for individuals to act upon. The literature cited above indicates that people do not know

how to translate general health education information into personal actions nor do they know

how to commit to taking health actions. Important insights for ENABLE’s intervention design

are obtained from extant research on self-referencing and commitment. To effectively change

health behaviors, communication cues need to personally engage the message recipients and

obtain a commitment from them. The third brief describes an ENABLE application to increase

personal relevance and commitment to engage in the health behavior.

------------------------------------

Insert Brief 3.0 Here ------------------------------------

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ENABLE Focuses on Implementation Mindsets and Plans

Health communicators often assume formation of a health plan is as natural and ubiquitous as the

formation of vacation plans. The result is health communication designers are often content to

raise awareness of health risks and leave implementation plans in the hands of the message

recipient. In contrast, ENABLE encourages employees to enroll by providing them with

implementation plans. Extant evidence on two popular models, TransTheoretical Model (TTM)

and Model of Action Phases (MAP) support the premise that absence of implementation plans

can impede health behavior change.

DiClemente and Prochaska’s (1998) TTM and Gollwizer’s MAP are influential frameworks

for explaining different decision-making phases and the challenges people face when attempting

to move from one stage to the next. The main organizing construct of both models is the stage of

change. TTM identifies six stages: Pre-contemplation, contemplation, preparation, action,

maintenance, and possible relapse. In TTM, the Decisional Balance construct reflects the

individual's relative weighing of the pros and cons of possible behavior change. For example, in

Pre-contemplation, the Pros of smoking far outweigh the Cons. In Contemplation, these two

scales are more equal. In the advanced stages, preparation, and action, the Cons of smoking

outweigh the Pros (Prochaska et al., 1994).

Gollwitzer (1987) identifies four MAP stages: pre-decisional goal setting, pre-actional goal

striving, actional, and postactional goal achievement. MAP identifies four tasks that need to be

completed to achieve goal fulfillment: 1) feasibility and desirability assessment to select which

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goals are to be pursued, 2) development of implementation intentions of what, where, when,

how, and with whom the actions will be undertaken, 3) responses to situational opportunities and

demands, and 4) evaluation of performance and re-assessment of goal desirability and feasibility.

MAP also describes how individuals function in different stages: a deliberative mindset is

used to select goals in the pre-decisional stage, whereas an implemental mindset is more useful

to form implementation intentions for preactional and actional goal striving. Compared to a

deliberative mindset which weighs the balance of pros and cons, an implemental mindset

prompts immediate action initiation and strengthens resolve and persistence (Beckman &

Gollwitzer, 1987; Gollwitzer & Kenny, 1989).

Alternatively, goals are abandoned if the individual does not then form a plan to undertake

new behaviors. New behaviors may require the acquisition of new skills and routines to deal

with internal (e.g., personal habits) and external (e.g., time constraints) challenges. The most

effective implementation intentions are those that link behavior to situational cues. Gollwitzer

(1993) and colleagues Heckhausen, and Retazcjak (1990) suggest forming a specific

implementation plan overcomes volitional, self-control problems, and makes behavior changes

more automatic as the new behavior is activated in response to cues in the environment.

The literature cited above highlights the advantage of an implemental mindset that would

promote movement from contemplation to preparation as well as increase resolve to attain health

goals. To effectively change health behaviors, communication cues need to suppress a

deliberative mindset and instead prompt an implemental mindset by providing an

implementation plan for the target behavior. An implemental mindset will be even more effective

among employees who are motivated, but who lack the ability to change their behavior.

Accordingly, ENABLE’s objective is to shift away from deliberation of pros and cons to a more 20

positive self-enhancing implementation motive to undertake the target health behavior. The

fourth and fifth briefs describe two ENABLE applications to increase the number of employees

who complete a Health and Wellness Assessment. The fourth brief demonstrates how a step by

step enrollment aid increased enrollment without increasing the financial incentive. The fifth

brief demonstrates the effectiveness of bundling health enrollment with the Health and Wellness

Assessment.

------------------------------------ Insert Briefs 4.0 and 5.0 Here ------------------------------------

ENABLE Uses Forced Choice to Highlight Status Quo Costs and to Reduce Procrastination

The convention in traditional health communication is to provide compelling information

persuade individuals to reconsider the status quo behavior in lieu of a more favorable option. In

most cases, respondents are encouraged to implicitly or explicitly opt-in for the advocated

behaviors. Failure to opt-in has resulted in alternative defaults such as opt-out or an automatic

enrollment default. Given the resistance to change and planning difficulties employees face,

some employers feel it may be best to take the planning decision out of the hands of employees

and rely on employer benefit plans. Recent examples include automatic employee enrollment

from brand to generic prescription drugs and requiring hospital employees to get a flu shot.

However, there are limits to using automatic enrollment: We cannot legally or ethically use

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automatic enrollment in some cases, such as requiring people to complete a health and wellness

assessment. Second, some research questions the long-term effectiveness of automatic

enrollment on responsibility and commitment (Lusardi & Keller, 2009). ENABLE uses an

alternative choice format, Enhanced Active Choice, which is designed to increase volitional

control to enable the individual to actively choose the healthier option.

Failure to opt-in has resulted in growing support for alternative enrollment defaults such as

opt-out or automatic enrollment. Participation rates for enrollment defaults are significantly

higher in domains such as organ donation (Johnson & Goldstein, 2003) and 401(k) plans (Choi et

al., 2002; 2004). Based on the initial success of automatic enrollment, the new health law

requires employers with two hundred or more employees to automatically enroll employees in

health benefit plans or pay a fine (Sec. 1511 of the Affordable Care Act).

‘Opt-out’ policies that automatically assign people to carefully selected default choices are

effective for a number of overlapping reasons. Loss aversion encourages people to stick with the

default because moving away from the default typically involves losses and gains, and losses

receive disproportionate weight (Johnson & Goldstein, 2003; Park, Jun, & MacInnis, 2000;

Samuelson & Zeckhauser, 1988). The effect of loss aversion is further exacerbated by present-

bias – the inordinate weight people place on costs and benefits that are immediate (Akerlof,

1982; O’Donoghue & Rabin, 1999a). Deviating from the default often incurs immediate, small

costs that are compensated for only by long-term benefits which, according to present-bias, are

sharply discounted.

Procrastination also works in favor of opt-out policies, again because deviating from the

default often involves positive action, which people commonly procrastinate in taking. People

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procrastinate for a variety of reasons including present-bias (see, e.g., Akerlof, 1982;

O’Donoghue & Rabin, 1999b), as a way of coping with anxiety and fear (Luce, 1998), and in

part because they are unrealistically optimistic that they will have more time in the future to

make a better informed decision (see incentives for procrastinators, Ariely & Wertenbroch, 2002;

Dhar & Simonson, 2003). Procrastination is in part a manifestation of the age-old adage that the

best (in this case, making an informed decision in the future) is the enemy of the good (making

an adequate, if not perfectly optimal, choice now) (Mukhopadhyay & Johar, 2005; Zauberman &

Lynch, 2005). Finally, opt-out policies exert such a strong influence on behavior in part because

people assume that defaults have been selected for a reason – i.e., that defaults constitute implicit

recommendations of specific courses of action (McKenzie, Liersch, & Finkelstein, 2006).

Despite automatic enrollment’s promising results, it is prudent to examine choice structures

that do not contain enrollment defaults. From a public policy perspective, it is illegal or unethical

to use automatic enrollment in some cases, such as requiring people to get screened. From an

individual’s perspective, the shared optimum inherent in an automatic enrollment plan may be

inappropriate or unsustainable, highlighting the need for education, individual responsibility, and

commitment. Putting aside the potential limitations of automatic enrollment for the individual or

society, we need non-default choice structures to persuade people to act in their best interests

after they have been enrolled. For instance, in a health and wellness context, we might want

employees to sign up for online health coaching to improve their health.

Active choice is an alternative no default forced-choice alternative. Unlike defaults such as

opt-out or opt-in, the “required choice” approach does not have a default; indeed, the key

element of the policy is to require decision-makers to make an explicit choice. Instead of waiting

for people to opt-in, Spital (1993; 1995) found support in public opinion surveys for the idea of

23

forcing people to choose whether they want to donate their organs. Sixty-three percent of a

random sample of 1,000 adults in the United States said they would support mandatory choice

(Spital, 1993). In a subsequent national survey, of the 30% of those who had previously decided

to donate, 95% said they would still do so under mandated choice (Spital, 1995). Spital (1996)

recommends using a mandatory plan wherein all adults would be required to record their wishes

about organ donation and those wishes would be considered binding.

Enhanced Active Choice is an extension of Active Choice: Instead of forcing people to

answer yes or no, Enhanced Active Choice highlights status quo costs and benefits of the social

desirable option. Enhanced Active Choice is best used in situations in which policymakers have

evidence that one option is generally superior. Director of Health Promotion and Wellness Although

it may appear obvious, reminding people of what they will lose if they opt for the non-preferred

alternative can have a powerful impact on choice because individuals are unlikely to seek out

information about the costs of remaining with the status quo when unprompted (Thaler &

Sunstein, 2008), especially if such thoughts evoke negative emotions like anxiety and regret

(Luce, 1998; Schuman & Presser, 1977). Dislike for the non-preferred alternative will be more

marked when the costs of non-compliance are highlighted in the choice format. Accordingly,

ENABLE’s objective is to shift away from an opt-in, opt-out, or automatic enrollment default

option to a more empowering, self-enhancing forced-choice format that bestows control on the

employee. The sixth brief describes an ENABLE Enhanced Active Choice application to prompt

enrollment.

------------------------------------

Insert Brief 6.0 Here ------------------------------------

24

Conclusion

Workplace wellness programs have achieved a high penetration in the United States, and most

observers expect that uptake will continue to increase, especially since the Affordable Care Act

will increase employment-based coverage and promote workplace wellness programs through

numerous provisions. While employer sponsors are generally satisfied with the results of

wellness initiatives, more than half stated in a recent survey that they could not quantify their

health program’s return on investment. The use of incentives to promote employee engagement,

while increasingly popular, remains poorly understood, and it is not clear how the type (e.g., cash

or noncash), direction (reward versus penalty), and strength of incentives are related to employee

engagement and outcomes (Keller & Lehmann, 2009). There are also no data on potential

unintended effects, such as discrimination against employees based on their health or health

behaviors (Mattke et al., 2012).

This chapter identifies ten new guidelines for designing more effective health interventions in

a tool called ENABLE. The advantage of ENABLE is it bestows control on the individual by

placing the individual, rather than the health issue, at the center of the intervention. Unlike

traditional health messages, which leave it up to the individual to identify options and/or urging

the individual to take healthy actions, the Enhanced Active Choice format gives the individual

options and control. Voluntary change in behavior is enhanced by highlighting status quo costs.

In contrast to the common view that inaction has no cost, ENABLE encourages employees to

recognize the costs associated with inaction, something most of us unlikely to do naturally. This

also entails commitment to a course of (in)action rather than the suspension of a viewpoint, 25

which is typically responsible for procrastination. ENABLE interventions employ a choice

architecture that presents simple, accurate choices to enhance commitment and prompt

immediate action.

ENABLE guidelines are firmly grounded in the literatures of behavioral economics,

consumer behavior, and psychology. The literature indicates a variety of discounting strategies in

response to a fear-arousing health appeal. In addition, individuals tend to under weigh

opportunity costs and place too much emphasis on managing potential losses and accompanying

regret. Additionally, research on decision stages highlights the challenge of goal formation and

implementation plans. Given these odds, it is not surprising employees are unwilling or unable to

participate in corporate wellbeing programs, especially if they are asked to undertake behaviors

that exact immediate or short-term costs for long-term gains.

Currently, attempts to inform individuals about the seriousness of long-term consequences

are not motivating them to choose healthy options over their relatively unhealthy status quo

behaviors. The convention in health communication is to provide fear-arousing information to

motivate individuals to reconsider or change their status quo behavior in lieu of a healthier

option. These communications do not empower recipients by increasing personal relevance,

confidence, or commitment to undertake recommended healthy actions. There is also no pressure

to take immediate action or take advantage of other imminent enrollment decisions. The six field

tests provide strong evidence that ENABLE’s combination of health messages, financial

incentives, and choice architecture are an effective low fear arousal method to increase

relevance, commitment, immediacy, and participation in health programs.

ENABLE recommends combining gain and loss frames. Individual characteristics can make

it difficult to align message frames with health behaviors because the framing literature provides 26

conflicting evidence on frame selection. The literature is equivocal on which frame is most

effective when perceived risk is low (high) for a detection (prevention) behavior. For example,

both frames, gain and loss, may be ineffective for an individual who may not view a cholesterol

detecting test as risky because s/he is not overweight nor has a history of heart problems.

ENABLE guidelines are a clear departure from extant practice in corporate wellbeing

programs. Although several ENABLE guidelines are followed in each study, different field

studies are selected to highlight unique ENABLE features. The first field study demonstrates

how an ENABLE intervention that overcomes compliance barriers - for example, indicating the

length of the health detection test - increases self-efficacy and participation in biometric

screening without increasing the financial incentive ($50). The second field study shows the

value of mixing message frames to increase regret aversion for not getting a flu shot. The third

study highlights how to increase personal commitment for a prescription drug refill program. The

fourth and fifth studies indicate how a combination of implementation plans, benefits enrollment,

and deadlines increase employee participation in health and wellness assessments without

changing the financial incentive. The sixth study provides strong support for Enhanced Active

Choice, a forced choice format to increase enrollment in a prescription drug refill program.

Although ENABLE can be used in different contexts, this chapter highlights the

effectiveness of ENABLE to enhance employee participation in corporate health programs. The

key effectiveness metric is program participation level. New evidence is needed to test whether

the ten ENABLE features can be used to design weight loss and smoking cessation health

maintenance programs. For example ENABLE can be applied to create new worksite

environments that promote healthy behavior, with on-site fitness facilities or subsidized gym

memberships, healthy food in common areas and fitness breaks during the day. ENABLE can

27

also be used to promote use of health coaches and other similar cost-effective health

interventions. Corporations are encouraged to use these cost-efficient, effective behavioral levers

to motivate and empower employees to improve their health and adopt healthy lifestyles.

28

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Figure

Comparison of the ENABLE and Conventional Dimensions for Six Health Applications

Conventional Dimensions ENABLE Dimensions Wellbeing Application

High Fear Arousal Low Fear Arousal Biometric Screening (see Brief 1)

Threat Appraisal Coping Appraisal Biometric Screening (see Brief 1)

Loss Frames/ Loss Aversion

Mixed Frames/ Regret Aversion

Flu Shot (see Brief 2)

Impersonal Personal Prescription Automatic Refill (see Brief 3)

Low Commitment High Commitment Prescription Automatic Refill (see Brief 3)

Deliberation Mindset Implementation Mindset Health and Wellness Assessment (see Brief 4)

Context Independent Context Dependent Health and Wellness Assessment (see Brief 5)

No Deadline Deadlines Health and Wellness Assessment (see Brief 5)

Health Benefits Status Quo Costs Prescription Automatic Refill (see Brief 6)

Opt-In Enhanced Active Choice Prescription Automatic Refill (see Brief 6)

35

Brief 1.0

ENABLE Intervention to Reduce Fear Arousal and Increase Self-Efficacy

Background: An educational institution wanted to increase employee participation in biometric

screening. Despite various attempts, benefit fairs, brochures, emails, face-to-face department

visits, and a $50 financial incentive to appear in the employees next pay check, only 30% of

employees took advantage of the free biometric screening. The low participation rate motivated

the educational institution to reconsider the appeal displayed below.

Previous Biometric Screening Enrollment Message

ENABLE Intervention: The ENABLE message identifies three barriers: Insufficient time,

privacy concerns, and lack of clarity/ease of making an appointment. Each of the barriers are

acknowledged and addressed in a single page email displayed below. Health issues are not

mentioned to keep the level of fear arousal low. Instead the focus is on increasing employee

ability to get the biometric screening.

36

ENABLE Biometric Screening Enrollment Intervention

Results: To compare the effectiveness of the ENABLE tool, a study was designed to compare

enrollment rates among employees who received the first communication with rates after the

same employees received the ENABLE message (n = 4300). The ENABLE message resulted in

a 37% increase in the number of employees who completed a screening, from 30% employee

participation to 41% employees screened. This result was even more impressive because there

was no change in financial incentive and there were only two opportunities to get screened.

37

Brief 2.0

ENABLE Intervention on Mixed Frames that Create Regret Aversion

Background: A hospital wanted to increase the effectiveness of flu shot reminders it sent to its

employees. Hospital employees seemed to be inoculated against pleas to get a flu shot despite a

$50 copay deductible. Emphasis on the dangers of getting and passing the flu virus on vulnerable

patients were not persuasive.

ENABLE message: Employees in the ENABLE condition were asked to choose between two

options: Place a check in one box. “I will get a Flu Shot this Fall to reduce my risk of getting the

flu and I want to save $50” or, “I will not get a Flu Shot this Fall even if it means I may

increase my risk of getting the flu and I don’t want to save $50”. The ENABLE message

used a combination of loss (I will get a Flu shot to reduce my risk of getting the flu) and gain (I

will not get a flu shot even it increases my risk of getting the flu) frames to accommodate

differences in employee involvement. Employees also rated why they wanted to get a flu shot on

several 1-7 scales including whether they would regret it later if they did not get a flu shot (regret

aversion).

Results: To compare the effectiveness of the ENABLE message, flu shot intentions were

compared for employees who were simply encouraged to get a flu shot (n = 30) versus the

ENABLE mixed frame intervention (n=30). The ENABLE intervention resulted in significantly

higher intentions than the conventional health message (25% vs. 67%). Employees also

expressed more concern about regretting not getting a flu shot when they received the ENABLE

message (Mean = 4.95) than the conventional health message (Mean = 3.53).

38

Brief 3.0

ENABLE Intervention to Increase Personal Relevance and Commitment

Background: A Pharmacy Benefit Manager (PBM) wanted higher enrollment in an automatic

prescription refill program. The PBM was inviting members who were receiving their

maintenance prescription drugs via mail to join the PBM’s free automatic prescription refill

program, ReadyFill@Mail (the PBM’s automatic prescription refill program) by simply clicking

on each prescription or the red box “Enroll me in ReadyFill@Mail” for all eligible drugs.

Enrolled members would then not need to call their doctors for prescription refills. The main

health advantage for enrollees are convenience and a lower likelihood of drug non-compliance

due to gaps in supply.

Previous Automatic Prescription Refill Enrollment Message

39

ENABLE intervention: ENABLE required members to question whether they liked managing

their own prescriptions. This intervention was designed to prompt self-referencing and make the

message more personal. Specifically, members were required to select one of two options: “I

prefer to manage my own refills” or “Enroll me in ReadyFill@Mail” before they could complete

their mail prescription drug requests on a subsequent web page. A sample ENABLE web page

appears below.

ENABLE Automatic Prescription Refill Enrollment Intervention

Results: To compare the effectiveness of the ENABLE message, enrollment rates were compared

among those who received the traditional invitation (n=4232) with those who were given the

ENABLE message (n=6950) and could not navigate further within the website without making a

choice. To assess commitment, disenrollment rates were compared for the two conditions.

40

The ENABLE message resulted in significantly higher member enrollment in the automatic

prescription refill program than the conventional message (21.9% vs. 12.3%). Interestingly, those

who received the ENABLE message also filled more prescriptions when they got the ENABLE

message (Mean number of scripts = 2.12) than the conventional message (Mean number of

scripts = 1.78). The ENABLE message did not result in lowering commitment. Members in both

conditions could dis-enroll at any time. Average time to withdraw was 12 days. 84.8% of

members remained enrolled in the ENABLE condition, whereas 89.8% of members remained

enrolled in the conventional condition. This difference is statistically significant although not

quantitatively very large. High rates of dis-enrollment are mainly due to discontinued

prescriptions.

41

ENABLE Brief 4.0

ENABLE Intervention to Facilitate an Implementation Mindset

Background: An education institute wanted to increase employee participation in a health and

wellness assessment for a new insurance carrier. An ENABLE intervention with implementation

guidelines was used because several employees expressed frustration with the online registration

and completion process. A typical response reflected unfilled desires – “I wanted to but could not

get past registration”. Employees were ignoring requests to call the help line if they had any

trouble. A copy of the invitation prior to the ENABLE intervention is presented below.

Previous Health and Wellness Enrollment Message

ENABLE Intervention: The ENABLE message consisted of six web page screen shots with a red

circle around the main challenge on each enrollment step. For example, the identification number

request was circled on the registration page to help members anticipate where they might get

42

stuck. Solutions were provided for each of the six pages, for example, employees were told they

could use their social security number instead of their employee identification number.

ENABLE Health and Wellness Assessment Intervention

Results: Participation rates before and after the ENABLE message were used to test the

effectiveness of the intervention. The ENABLE message significantly increased the number of

employees who participated in the Health and Wellness Assessment (30% vs. 58%). These

results were more impressive because the same employees had not responded to previous non-

financial and financial appeals to complete the Health and Wellness Assessment, and the

increase was observed in a mere two weeks after the ENABLE intervention.

43

ENABLE Brief 5.0

ENABLE Intervention to Take Advantage of Context and Deadlines

Background: A hospital wanted to increase the number of employees who completed a health

and wellness assessment. Despite a number of messages on the importance of understanding

one’s health and a $200 copay deductible for completion, only 37% of approximately five

thousand employees completed the Health and Wellness assessment. A copy of the invitation

prior to the ENABLE intervention appears below.

Previous Health and Wellness Enrollment Message

ENABLE Intervention: The ENABLE intervention was bundled with the annual health benefits

enrollment at the hospital. Hospital employees had to make a commitment to either complete or

not complete the HWA before they were able to access the benefits enrollment site. Employees

were asked to choose one of two options: “I prefer to take advantage of this free tool to maintain

or improve my health and save $200” or “I prefer not to take advantage and decline this

opportunity to get help in maintaining or improving my health and wellbeing”. A snapshot of the

website prior to benefits enrollment is displayed below. The annual benefits enrollment context

and deadline for enrolling in medical benefits was expected to increase employee Health and

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Wellness completion because it should be more difficult for employees to disregard learning

more about their health when they were about to pay for their health care (health enrollment

period)!

ENABLE Health and Wellness Assessment Intervention

Results: After receiving the ENABLE message, an additional 30% of hospital employee (n =

1500) completed the health and wellness assessment in five weeks. This result was even more

impressive because there was no change in financial incentive and the same employees had

already rejected previous pleas.

• Visit the Health and Wellness Assessment (HWA) website to develop an action plan to maintain or improve your health. Now, or whenever you are ready, you will have free access to powerful online coaching tools for success.

• If you have already completed or plan to complete the HWA, you will receive an annual $200 off your bi-weekly or monthly health insurance contribution cost.

• The Health and Wellness Assessment is administered through HealthMedia and is confidential. Results from all HWA responses will be summarized, without identifying individuals, to determine trends in employee health.

I prefer to take advantage of this free tool to maintain or improve my health and save $200.

I prefer not to take advantage and decline this opportunity to get help in maintaining or improving my health and wellbeing.

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ENABLE Brief 6.0

ENABLE Intervention on Status Quo Costs in an Enhanced Active Choice Format

Background: A Pharmacy Benefit Manager (PBM) was interested in increasing enrollment in

their trademarked automatic prescription refill program, Readyfill@Mail. The PBM was inviting

members who were receiving their maintenance prescription drugs via mail to join the PBM’s

free automatic prescription refill program. Enrolled members would not need to call their doctor

for a prescription refill. The main health advantage for enrollees is convenience and less

likelihood of drug non-compliance due to gaps in drug supply.

ENABLE Intervention: Prior to the ENABLE intervention, the PBM was using an automatic

phone service to invite members to join the ReadyFill@Mail program. Unfortunately, rather than

pressing 1 to be transferred to Customer Care and enroll in ReadyFill@Mail, members were

hanging up or declining by pressing 2. An ENABLE intervention was used in the new phone

message. Members in the ENABLE condition were asked to “Press 1 if you prefer to refill your

own prescription by yourself each time” or to “Press 2 if you prefer the PBM to do it for you

automatically”. Compared to the web-page study (Brief 3.0), there was no forced choice in this

study. The emphasis on “each time” was used to motivate members to deliberate on status quo

costs.

ENABLE Results: All members who chose to enroll were transferred to the PBM’s customer

service representative. To compare the effectiveness of the ENABLE message, a study was

designed to compare enrollment rates among members who did not receive the ENABLE

intervention (n=5491) with members who were given the ENABLE intervention (n=4459). To

assess commitment, members in both conditions were given a toll-free number to call if they

wished to discontinue enrollment at any time.

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The ENABLE intervention resulted in significantly higher member enrollment than the

conventional phone message (32.0% vs. 15.7%). The ENABLE intervention did not result in

lower commitment. Members in both conditions could dis-enroll at any time. Disenrollment was

virtually identical (22.1% vs. 21.4%) when the ENABLE intervention was absent or present.

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