Safety Scratch Offs

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Easy-to-implement program where you distribute scratch off cards worth points toward trips and prizes. Learn More

 

Online Points Program

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Customize your own points program and give employees the ability to redeem points online. Add it as an overlay to any BBS or safety program.

Why Prochaska Was Wrong

By Bill Sims


GASP!
What???

Forgive me for having second thoughts about Prochaska's Stages of Change theory.  For years, like many, I have felt that the Stages of Change model was THE definitive approach to changing human behavior. For those of you who are a little rusty on this topic, the theory states that any type of human behavior change has 5 stages:

  1. Precontemplation-You have the problem but have no intention of changing behavior
  2. Contemplation-You recognize the problem and are seriously thinking about a change
  3. Preparation-You intend to change behavior but have not consistently done so
  4. Action-BAM! You changed your behavior
  5. Maintenance-You maintain the behavior change for 6 months or more

The model above has been held as the Holy Grail of wellness intervention for many years. The idea goes that you should only try to move people from one stage to the next stage....e.g., find all the smokers who are in Contemplation or Preparation and target your efforts at these, with the assumption being that it is pointless to change the behavior of people who are not at Stage 2.

I always wondered what would happen if we took the most die hard smoker (who is at stage 1 and gave him this proposal:

If you stop smoking we will pay you $1 million for every day you are smoke free.
If you keep smoking we will strap you to an electric chair and kill you.

According to the Stages of Change Theory, we would be wasting our time in this experiment, because the smoker isn't ready to change. The theory holds that he would forego the daily million dollar payout and keep smoking until we push the button on the electric chair.

But we all know this isn't the case. Given the choice of immediate death, and immediate wealth, 90% or more of these Stage 1 people will change their behavior.

For quite awhile I struggled to make sense of all this, and then I went to a course by Dr. Aubrey Daniels, in Atlanta, Georgia.  For those of you who really want to gain a new approach to behavior change, you can attend his workshop, as I did. Or you can just read his book, "Bringing out the Best in People".

Or, you can watch our workshop on Green Beans & Ice Cream  found at www.billsims.com/webinar.htm and review my presentation in Athens Greece please or South Africa.

Before I delve into the field of Behavior Analysis, let me mention that human behavior change has been achieved successfully for years in a field that sits just one door over from wellness: occupational safety.

Using advanced techniques of behavior analysis and coaching, thousands of companies have changed employee behavior so as to eliminate unsafe actions and behaviors which in turn have resulted in elimination of 99% of all on the job injuries.

So successful have these efforts been that in the last 25 years we have seen workplace safety improve to the point that you are now 10 times more likely to be killed going home from work than while you are on the job.

A. What are the techniques that have helped Safety Managers change human behavior and save millions in the process?

B. Why is the ABC theory more important than Stages of Change in wellness?

C. Why are the most popular kinds of wellness incentives also the least effective?

All of this and more we will now discuss...

a) What are the techniques that have helped Safety Managers change human behavior and save millions in the process?

Please don't zone out and say "oh, that is for safety, so it isn't relevant to me".  Safety behavior change is a great model to study, since it has been around much longer than wellness behavior change, and as such, it has matured fully.

In fact, we can apply the lessons we have learned in 25 years of developing over 1,000 of these programs to the new challenges of wellness behavior change.

First off, the ABC model holds that every Behavior has three actual components.
The ANTECEDENT gets you to see the need for the behavior, then the BEHAVIOR occurs, and the CONSEQUENCES follow.

For example, when you are hungry (ANTECENDENT) you eat (BEHAVIOR) and it tastes good (hopefully) and fills you up (CONSEQUENCES).

There are many antecedents around us all the time: stop signs, billboards, tv ads, etc. and these do a good job of getting a behavior to occur ONE TIME.

It is the job of the CONSEQUENCES to get us to repeat the behavior a number of times.

Here is a common wellness problem that demonstrates the ABC process in action.

You are hungry and so you eat a Krispy Kreme Doughnut.  The consequences that follow immediately (if you are like me) are:

-it tastes great
-it fills you up
-you want more

All of these consequences are POSITIVE, IMMEDIATE, and CERTAIN.

They drive people to eat donut, after donut, after donut.

Now, there are also negative consequences to eating these donuts:

-I might get fat
-I might get diabetes
-I might have a heart attack

These  NEGATIVE consequences however, are FUTURE and UNCERTAIN (because hey, I could get hit by a bus tomorrow and so I don't have to worry about getting fat).

Now, what you should begin to see is that PICS (positive, immediate, certain) are the most powerful kinds of consequences to sustain a behavior whiles NICS (negative, immediate, certain) are the best at stopping a behavior. However, NICS must be used as a last resort since when we use them we will lose much of the morale and discretionary effort that we want our employees to have.

Using the PIC model, it is easy to see why people keep smoking (PICS keep them doing it while the negative consequences of cancer are uncertain and future) and why people give up diet and exercise (because there are plenty of NICS in the early stages of those behavior changes and almost no PICS)

PICS have been used billions of times to change safety behavior (e.g. wear your hardhat, lift with your legs not your back) but we are only beginning to understand their power with wellness change.

Further, we see a vital need to focus on early, upstream behavior change.

Instead of only rewarding the people who lost 30 pounds (trailing indicators) we should positive reinforce people the FIRST DAY they change behavior and order that salad instead of the usual cheeseburger.

Ok, so I think I've pretty much nailed points a) and b) above...now let's look at
our last question...

c) Why are the most popular kinds of wellness incentives also the least effective?

Over 75% of all companies using wellness programs have decided to use an incentive (that's good, cause we need more PICS) but over 80% of those same companies in our study say that they are not reaching HIGH and MEDIUM risk employees who drive 70% of their healthcare costs.

Why?

What's wrong with this picture?

There are several problems with the current approaches to wellness incentives which cause them to be less than successful.

The top 3 most popular incentive choices according to our Welcoa survey of over 400 firms are:

Cash-25%
Health Insurance discounts-25%
Gift Cards-15%

Tangible reward programs are only 6% of the market. So why are the big three failing to deliver sustained wellness behavior change?

In fact, recent study by SHPS states conclusively that cash & health insurance discounts are the most popular incentive choices, and it concludes that they are most effective. But this conclusion is wrong.

Let's dig deeper into the numbers.

Companies who awarded their employees for wellness participation and used Health Insurance discount spent $450 per employee per year...OUCH! And they only got 50% participation. Divide the numbers together and you will see that you are going to spend $9 per employee per percentage point of participation.

On the other hand, companies who awarded employees with Cash spend $210 per employee per year and achieved 70% participation. Do the same math and you will see that cash is a clear winner over healthcare discounts at a factor of $3 per employee per percentage point of participation.

However, the group of companies who used tangible merchandise drawings spent a paltry $3 per employee per year and still got 32% participation...so on a dollar for dollar basis, tangible reinforces produced better results than cash or healthcare discounts!

Why is this so?

Because Healthcare discounts, while they are positive, are NOT IMMEDIATE and CERTAIN. You might get hit by the bus before you ever get to cash in those chips.

Cash is clearly a much better PIC, as is shown by it's results, BUT, we should factor in 3 studies done by Mazda, Goodyear, and University of Waterloo.

In the studies, people were asked "what should we give you to reward you for doing something extra?" such as taking a health survey etc. 82% of the employees said "Give us the money, honey, cause cash is king."

This typical response is the reason that so many studies such as the one by SHPS conclude that cash is the most effective motivator.

But the Waterloo study proves that conclusion false. They gave half the employees $100 cash to complete a survey and the other group received a tangible reward (e.g. that $100 ipod she always wanted but they were in debt on their credit cards and the baby needed new shoes).

People who were given a tangible reward worked 3 to 6 times harder than those who got money, which is usually used to pay down bills.

What can we conclude  from this?

If all factors are equal, the use of a tangible and income tax free reinforcer will provide greater ROI than CASH ever will. In short, if we spend $210 per person per year on a tangible reinforcer program that offers IPODS, Trips, and many other tangibles, we will see greater participation than the cash program where almost half of the budget goes to income tax, and the remainder becomes a payment on the visa bill.

Last, and perhaps most important, most wellness incentive programs have become an "entitlement".

In the early 80's we built wellness incentive solutions for the Home Depot, Bank South, and AT&T.

Following the best advice of the wellness gurus of the day, we would typically reward people for things like signing up for a walking program.

Usually, we'd give a Tshirt and a Water Bottle.

With few exceptions, the people who signed up were healthy, already walking 3 times weekly, and were our low risk employees.

We went to the 8th floor where the overweight, chain smoking operators were and asked them why they didn't sign up for our program to win this really cool water bottle and t shirt.

They laughed us out the door.

So at the end of the day we didn't get behavior change from anyone.

Our low risk folks were walking already....we just gave them a free t shirt.
Our medium & high risk folks were telling us that it would take a much bigger PIC than a t shirt to get them to make all the behavior changes they would have to make to get healthy.

And not much has changed today. Whether companies use gift cards, FSA contributions, cash, or t-shirts, they are continuing to reward mostly their healthy, low risk employees.

What is needed is a strategic approach to incentives that matches the PICS with the risk. That means that we need a bigger carrot for medium & high risk folks. And a little something for those who are low risk.

Our research shows that 4 out of 5 wellness programs still fail to get the medium & high risk people on board. Now I know some will whine when I say that we should stop giving away the candy store to our healthy people. But many of these low risk health folks will switch jobs 2 to 4 times till they settle down.

It's time to start viewing our employees as Triage in the ER. We need to put our money and resources where are medium and high risk folks are--since they drive 70% of our healthcare costs. We also should understand that Stages of Change is a good map to have, but the engine of behavior change is managing the positive consequences effectively for each person.

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