Stanford Behavior Design Thesis: Improving Employee Wellness Programs

Behavior Design for Optimizing Employee Health:

Creating a Behavior Design Evaluation Tool to Identify Strengths and Weaknesses in Physical

Activity Wellness Programs

David Ngo

Behavior Design

Stanford University

May 1, 2013

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ACKNOWLEDGEMENTS I want to let the first words in this thesis convey my gratitude to everyone who played a

huge part in this journey. From my individually designed major in Behavior Design to

ultimately this senior thesis, I am eternally thankful for this experience – and for you all.

Sincerely,

David Ngo

Dr. BJ Fogg

Dr. Kyoko Sato

Andrew Gold

Beth Ann McKeown

Dr. Stephanie Habif

Dr. Jeremy Bailenson

Jennifer Sexton

Sheila Booth

Dr. Clifford Nass

Dr. Carol Dweck

Catrina Lee

Susan Weersing

Dr. Stephanie Habif, you have taught me so much throughout this thesis process. Your direct advising, weekly feedback, and encouragements made this journey worthwhile. Thank you. Andrew, Jennifer, & Catrina, you are all leaders in your respective companies (Pitney Bowes, Stanford BeWell, & Gap Inc.). Thank you for your patience and time. I hope this thesis helps you as much as you all have helped me. Dr. BJ Fogg, you continue to help change my life directly and indirectly. Two years ago you exposed me to Behavior Design. I have not looked back since. Thank you. Dr. Clifford Nass, you have been so flexible and understanding through this thesis process and academic structure. Thank you for supporting Dr. Habif and me through this process. Dr. Jeremy Bailenson & Dr. Carol Dweck, you both supported my Behavior Design major in 2011. Thank you for believing in me. Dr. Kyoko Sato, you brought us your expertise in tackling this monster and kept us to our monthly meetings. Thank you for always telling us that this is a messy process and that it is okay. Beth Ann, Sheila, & Susan, you have made this all possible from the beginning. Without you all, I would not have been able to be Stanford’s first and only Behavior Design Major. Thank you.

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ABSTRACT

This senior capstone project aims to create a behavior design evaluation tool to identify

strengths and weaknesses in physical activity wellness programs. The “Behavior Design

Wellness Checklist Tool” (The Checklist for short) is based on three main bodies of

research in psychology: Dr. B.F. Skinner’s positive reinforcement, Dr. Robert Cialdini’s

principles of influence, and Dr. BJ Fogg’s Behavior Model. The Checklist was designed

and tested in collaboration with three companies: Pitney Bowes, Stanford University

BeWell, and Gap Inc. and tested against six total programs (two programs per company).

All representatives from partnered companies plan to use The Checklist in the near future

to make strategic design decisions about their wellness programs in order to increase

participation.

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Testimonials The Checklist acts as a guide to view programs from different perspectives and think through the design “It’s easy for programming people to think they’re doing the right thing. The Checklist helps with thinking about the program from multiple perspectives.” -- Jennifer Sexton, Director of Wellness Programs, Stanford University BeWell “[The Checklist acts] as a guide to ensure we are thinking through the various points during the inception of the program/event.” -- Catrina Lee, Senior Director of Talent Management, Gap North America

“Definitely helps me think through the design decisions.” -- Andrew Gold, Vice President of Total Rewards, Pitney Bowes

The Checklist positively impacts the program simplification process for increasing participation “…[helps] thinking through how to influence and make attendance easy…” -- Catrina Lee, Senior Director of Talent Management, Gap North America

“…helps me apply the principles that have been shown to help/motivate employees to take action.” -- Andrew Gold, Vice President of Total Rewards, Pitney Bowes

The Checklist highlights potential opportunities to reinforce behaviors during the process/program itself “…[helps thinking through] how to reinforce participation during the event.” -- Catrina Lee, Senior Director of Talent Management, Gap North America

“…I was looking at the workshop checklist and trying to figure out how we can give positive reinforcement during the process.” -- Jennifer Sexton, Director of Wellness Programs, Stanford University BeWell

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TABLE OF CONTENTS

I. Introduction ……………………………………………………...……... 6

II. Purpose & Motivation ………………………………...……....……….. 8

III. Current State of Wellness Programs …………………...…………….. 11

IV. Theories & Bodies of Research …………………………...………….... 16 a. Fogg Behavior Model and Motivation Waves by Dr. BJ Fogg ……………………… 8

b. Positive Reinforcement by Dr. B.F. Skinner ………………………………………… 18

c. Six Principles of Influence by Dr. Robert Cialdini ………………………………….. 20

V. The Behavior Design Checklist ………………………………………... 23 a. Glance Test based on Fogg behavior research ……………………………………… 23

b. Reinforcement Test based on Skinner reinforcement research ……………………… 25

c. Influence Test based on Cialdini influence research ……………………………….. 27

VI. Case Studies: Wellness Programs Evaluated Using The Checklist … 29 a. Pitney Bowes …………………………………………………………………………. 30

b. Stanford University BeWell ………………………………………………………….. 38

c. Gap Inc. ……………………………………………………………………………… 45

VII. Insights & Recommendations …………………………………………. 52 a. Positive reinforcement at random frequencies are weak ……………………………. 52

b. “Calendar Taps” is a strong trigger because it increases commitment …………….. 53

c. Elevator Ads are great triggers if employees can act in <7 seconds ………………... 54

d. Buy in from high-authority superiors and respected colleagues …………………….. 55

e. Limited enrollment used for any new or weak programs ……………………………. 56

f. Too much text: not enough visual social proof on websites …………………………. 57

VIII. Conclusion ………………………………………………………………. 58

IX. Appendix ………………………………………………………………... 60

X. Bibliography ……………………………………………………………. 63

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I. INTRODUCTION

For hundreds of thousands of years, humans had to run, hunt, and move several

hours a day in order to survive. These days, most humans can move very little throughout

the day and still survive by doing their jobs. Sedentary behavior has become the new

human norm. Imagine 200 centuries of daily physical movement for survival. Fast

forward and imagine what most people do now throughout the day: sit at a desk, sit on a

plane, walk to the bathroom, walk to the kitchen, lay on the couch, and lay in bed. Now

imagine the human health effects of not physically engaging the human body after 200

centuries of daily physical movement. Sitting is the new smoking (Levine 1999).

Most large corporate organizations - such as fortune 500 companies and

universities - offer programs to better the health of its employees (known as “wellness

programs”). However, companies and institutions are not getting the highest return on

their investment because there is 1) a lack of understanding of how human behavior

really works, and 2) no systematic method for assessing the efficacy of wellness

programs before managers invest/launch programs. Corporate wellness leaders need a

way to apply human behavior insights to their programming.

Although this first iteration of The Checklist focuses on physical activity

programs, it can be applied to any behavior-change-focused project. The learnings and

products of this thesis transcend the wellness world in that it serves to identify the

strengths and weaknesses of both online and offline wellness programs, events, or

offerings.

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RESEARCH QUESTIONS:

This thesis answers three main research questions:

1) What are the conventions of current corporate physical activity wellness programs?

2) Which factors indicate most attended and least attended physical activity wellness

programs at Pitney Bowes, Gap, and Stanford University)? *Note: Stanford will be called a

‘company’ for the sake of consistency*

3) How might The Behavior Design Checklist help companies assess the potential

efficacy of a physical activity wellness program?

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II. Purpose & Motivation:

The Food and Drug Administration (FDA) has a systematic way of assessing

potential drugs based on the safety and pharmacology (phase 1), effectiveness of the

compound (phase 2), safety, effectiveness, and optimal dosing (phase 3), and post-

marketing data that verifies the efficacy and side effects of the drug (Lipsky et al 2001).

A systematic checklist to assess the efficacy and safety of new drugs is key to making an

informed decision and having a high return on investment. There currently is no

systematic assessment option based on principles of behavior change for employers to

use to assess wellness programs.

The purpose of this thesis is to provide the first systematic behavior design

assessment tool to companies interested in bettering their physical activity wellness

programs. This tool equips employers with an easy-to-use checklist, called The Behavior

Design Checklist, to assess the potential efficacy of a wellness program before employers

actually invest in a program. By using The Behavior Design Checklist for Wellness

Programs, employers gain more confidence in their decisions about whether to invest in a

program. Similar to how the FDA team can feel confident in their decisions to approve a

drug, company wellness program leaders can feel more confident in their decision to

invest/launch a wellness program based on the criteria of applied psychology and

behavior design.

The Checklist, which is now shorthand for the Behavior Design Checklist for

Wellness Programs, arms decision makers with a tool to evaluate the potential success of

a program. This thesis developed The Checklist in collaboration with Pitney Bowes, Inc.,

Gap Inc., and Stanford University’s BeWell using research on behavior design. The

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Checklist was applied to 6 existing physical activity wellness programs. By reverse

engineering the most attended and least attended physical activity programs across

companies, the six program case studies enabled an iterative design of The Checklist.

The Checklist empowers company managers to make more informed decisions by

quantifying the quality of a wellness program. This thesis also provides ideas for

wellness program managers in the Case Studies section (page 29) and Insights and

Recommendations section (page 52). Gratitude for all three partnered companies, Pitney

Bowes, Gap Inc., and Stanford University BeWell for being bold, patient, and caring

enough to share their time, answers, and data.

PERSONAL MOTIVATION:

My personal motivation for writing this thesis is two-fold:

1) Love for Psychology and Behavior Design

Psychology captivated me in 6th grade when I wanted to hack my studies. I

wanted to spend less time studying, and more time playing – so how could I hack my

memory? What were the best strategies for learning? When high school came, I had a

better understanding of memory, learning, and cognition compared to the other 95% of

high school freshman (informed statistic).

My love for psychology eventually led me to Behavior Design in Spring 2011 at

Stanford University. Taking Dr. BJ Fogg’s 2011 Behavior Design class on using

psychology and technology to create calming habits changed my life. It gave me a

systematic way of thinking and applying psychology to other peoples’ lives: it opened

the pathway to an expertise that I might pull on to help design solutions for problems that

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deal with human behavior. And frankly, almost all institutions are fundamentally trying

to design human behavior, but most do not understand how human behavior works.

2) Designing Solutions that Better Peoples Lives

My desire to optimize life has led me to explore different applications of behavior

design, but in early 2012, I consulted with Dr. BJ Fogg, my mentor and professor. He

encouraged me to focus my research on healthcare behavior design because this would

optimize the lives of others. Health behaviors and habits, such as exercising and

nutritious eating, are keystone habits (Duhigg 2012). And the significance of keystone

habits, like exercising, is that they have a great spillover effect in our lives: keystone

habits will improve other areas of our lives that are seemingly unrelated to health, such as

work productivity and creativity (2012). My focus, therefore, is how to use behavior

design to increase healthy habits amongst employees in the United States.

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III. CURRENT STATE of WELLNESS PROGRAMS

Health insurance premiums will change for many Americans under the Affordable

Care Act. The Affordable Care Act (commonly known as ObamaCare) will also disrupt

the health insurance market, but the average increases in insurance costs are all

speculative. For many employees, this means that they are using more money to visit the

doctor’s office because of health-related reasons. For employers, this means that they are

paying more for the health insurance costs of their employees. Lifestyle diseases related to diet, lack of physical activity, and stress are primary

drivers of healthcare costs. Because full-time employees spend 7-9 hours per day at work,

companies have the opportunity to impact the negative impact of lifestyle diseases. By

designing quality health and wellness programs, employers can give employees the

chance to move more, eat less, and manager their stress.

Currently, all companies are pressured to show that their employee wellness

programs are effective by quantitatively improving the health of their employees. The

three main verticals that wellness programs focus on are physical activity, eating, and

stress management (mental/emotional health).1 Current wellness program directors are

seeking ways to increase participation in their employee wellness programs because

companies/partnered companies have low participation rates on average. One study

found that the overall participation rate among employees for worksite wellness programs

was 23% (McLellan et al. 2009); another study found the overall median participation

1 This thesis focuses on only physical activity wellness programs because tackling all three verticals exceeds the limitations of time and resources as an undergraduate senior.

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rate was 33% (Robroek et al. 2009). Pressure for results source from two reasons:

company financials (bottom line) and employee productivity.

Financials: Healthcare costs are rising and changing with the Affordable Care

Act. The unknown financial effects incentivize to trigger more of their employees

to engage in preventative health.

Productivity: companies are incentivized to design for employee health because

being healthy is highly correlated to being more productive, creative, and happier

in both the work and personal lives of their employees. (Kowlessar et al. 2011).

Because of the high demand for effective employee health solutions, companies spend

their money on employee wellness programs, consultants, and advisors to figure out how

to increase 1) participation in and 2) efficacy of wellness programs.

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CURRENT PROCESS & EXPERIENCE OF WELLNESS PROGRAMS Across all four companies studied, Pitney Bowes, Gap Inc., and Stanford University,

there is a conventional model of how employees are prompted to engage in wellness

programs (diagram below). Though the chronological order of the flow-chart (below)

may not be the same, the process is very similar across companies.

Figure 1a. Common Onboarding Experience for Wellness Programs

Step1: Employees learn about Health beneGits,

programs, and incentives

Step2: Employees take Health Risk Assessment

(HRA)

Step3: Employees might get a biometric screening

Step4: Employees meet with a health coach

Step5: Employee sign up for programs on their own

Step6: Employees participate in wellness

programs

Step7: Employees get another biometric screening

to measure results

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o Employees learn about health benefits, wellness programs, and

incentives: Employees will learn about all this information through the various

channels provided by the employer, such as emails, info sessions, brochures, and

appointments.

o Employees take the Health Risk Assessment Test:

Employees need to take the Health Risk Assessment (HRA), which takes about

20-30 minutes. For most companies, the Health Assessment Tests is seen as a

way to inform and educate employees about their own health.

o Employees get a biometric screening:

Employees go for a biometric screening - a 15-minute test that measures blood

pressure, cholesterol, glucose, and body-mass index (BMI). All three partnered

companies strongly recommend their employees to not eat or drink anything for

8-10 hours before the test (for more accurate test results). Biometric screenings

provide companies a quantitative employee health baseline.

o Employees meet with a health coach:

Employees then have to meet with a health coach, one-on-one, to discuss potential

options and resources that will better their health. Specifically, a plan of action

and goals are set during this meeting.

o Employees are left to sign up for wellness programs on their own:

Health coaches do provide recommendations for which programs to sign up for;

however, the actual act of enrolling for a specific program is left for the employee

to do.

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o Employees participate in physical activity wellness programs:

This is the stage that is the most important throughout this entire process. At this

stage, employees are actually participating in programs that require physical

activity.

o Employees go for another biometric screening:

Finally, this is the stage where employers capture data to measure how much

progress employees have made compared to the previous biometric screening.

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IV. THEORIES & BODIES OF RESEARCH

The Checklist is based on a behavior change psychology research. There are three levels

to The Checklist that is based on three main bodies of research.

1. Fogg Behavior Frameworks/Models (Dr. B.J. Fogg of Stanford University)

2. Positive Reinforcement and Variable Rewards (Dr. B.F. Skinner of Harvard University)

3. Six Universal Principles of Influence (Dr. Robert Cialdini of Arizona St. University)

Dr. B.J. Fogg’s Behavior Frameworks/Models

Stanford University psychologist Dr. BJ Fogg and his Behavior Design Lab (formerly

known as Captology / Persuasive Technology Lab) created two main frameworks for

thinking about human behavior that is pertinent to creating The Behavior Design

Checklist Tool.

Fogg Behavior Model defines exactly when a behavior will occur. In order for a

behavior to occur, three factors – motivation, ability, and trigger – must converge at the

same time (Fogg 2009). If any of the following three components are missing, then the

behavior will not happen. Motivation is the desire to do a behavior. Ability describes

how easy or hard it is to do the behavior. Trigger is the call to action to do the behavior.

Imagine that Bob and Susan have been physically inactive for >1 month. They

want to walk on a treadmill for 20 minutes every day at their local gym. Bob and Susan

schedule their own reminders on their calendars or phones (triggers). It is just the start

of a New Year 2013 so they are highly motivated to walk on the treadmill for 20 minutes

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(motivation). Because of the new motivation from New Years, they decide to start

jogging for 20 minutes a day (instead of walking) even though it’s harder (ability).

In the example above, the jogging behavior probably happens for the first couple

of days because the motivation is so high in the start of a New Year. Although it is great

that they jogged for 20 minutes for a couple of days, the habit of going to the gym every

day is the desired target behavior. Most people fail their resolutions and are unable to

design effective behavior change programs because they get their employees or target

users to do too much, too soon.

Figure 1b. Fogg Behavior Model

Motivation Waves is a conceptual and visual way to understand the variability of human

motivation. For example, Americans have a high motivation wave around New Years –

notice the excitement and determination people have for achieving hard goals like

consistently going to the gym. At other times, motivation levels are low, such as during

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Thanksgiving break: notice the lack of determination to exercise or start new behaviors.

Understanding when employees have high motivation and low motivation to do health

behaviors will not only save time and money, but also increase chances of employees

doing the target health behavior.

Figure 1c. Fogg Motivation Waves (Fogg

Positive Reinforcement

Another body of research that is essential to understanding how human behavior works is

through the work of psychologist Dr. B.F. Skinner at Harvard University. Because

psychologists Skinner and Pavlov are commonly confused, it is important to note that

Behaviorism (Operant Conditioning) is not the same as the work founded by Dr. Pavlov

and his salivating dogs (Classical Conditioning). Skinner pioneered the research of

positive and negative reinforcement and its effects on behaviors. His theory asserts that

all human behavior has been positively or negatively conditioned in a linear sequence.

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His research states that positively reinforcing a target behavior when the behavior is

happening will strengthen that behavior (Skinner 1958). For example, verbally praising

and encouraging employees while they are doing their biometric screening will

strengthen the likelihood of doing biometric screenings. If the positive reinforcer is

during the HRA (health risk assessment test), then the behavior of taking the HRA is

reinforced.

On the flipside, if a negative reinforcement is experienced during a behavior, then

that behavior becomes less likely and will be avoided in the future (Skinner 1958). For

example, if the person feels pain or the feeling of being left out while they are attending

the company gym, then they are most likely not going to return ever again. One way to

overcome a behavior barrier (i.e., lack of desire to take the Health Risk Assessment test)

is to incentivize them with a monetary reward for the completion of a behavior.

The difference between reinforcing during the behavior versus reinforcing for the

completion of a behavior hinges on the frequency of the behavior. Attending weekly

dancing classes or walking 10 minutes after every lunch should be reinforced DURING

the actual behavior because employers want these behaviors to be performed frequently.

Taking the Health Risk Assessment Test or Biometric screenings are reinforced for the

completion because these behaviors are performed annually. In other words, reinforce

DURING behaviors to turn them into habits, such as attending a Yoga class weekly;

reinforce via incentives (no greater than $500) UPON COMPLETION for “one-time”

behaviors such as doing biometric screenings (Marteau 2009).

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Six Principles of Influence by Dr. Cialdini

The six universal principles of influence discovered by Dr. Robert Cialdini serve as

another body of research to measure the efficacy of the studied employee wellness

programs. Below are descriptions of the six principles of influence and applied examples

of each principle.

Authority describes our inclination to heed the words from figures of authority. Cops,

teachers, coaches, and bosses are examples of authority figures. We naturally learned to

obey figures of authority: early in our lives, people like teachers and parents had more

knowledge than we did; thus, following their advice and wisdom at a young age mostly

resulted in rewards and beneficial circumstances. In other words, authority figures were

both superior in knowledge and usually controlled the positive or negative reinforcement

to our behaviors when we were young (Cialdini 1993). Even now, we seek and heed

suggestions from figures that have expertise or control the rewards/punishments.

Commitment/Consistency describes our human tendency to stay consistent with

our commitments whenever we make one (Cialdini 1993). Gap Inc. has programs that

allow employees to sign up as “Health Advocates.” The role of a Health Advocate is to

organize health-related activities and encourage fellow employees to stick to their health

goals. Once employees become Health Advocates, they are more likely to consistently

perform healthy actions. If the Health Advocate role includes “exercises at least 3x a

week,” then these employees will be more likely to exercise 3x a week than non-advocate

employees.

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Scarcity describes our human heuristic, a mental shortcut, to place a high value on

things that are scarce or rare (Cialdini 1993). Think equating “limited quantity” to

“valuable.” Imagine products that are advertised by current companies that say “for a

limited time only!” or “sold out!” Diamonds are the archetype example of using the

principle of scarcity to make them the most precious stones on earth (Epstein 1982).

Abundance and convenience characterize the offerings of these wellbeing programs; for

example, there is no shortage for health coaches, or amount of classes, or health risk

assessment tests. There, however, are specific instances of the scarcity principle being

used: limited enrollment in classes and limited incentives (gift cards and t-shirts).

Similarity describes our human inclination to like and favor those who are similar to us

(Cialdini 1993). Like a close group of friends— how many things are similar amongst

them? Applied to the wellness world, a single mother of two who sees men participating

in a class is less likely to participate than if the single mother saw other single mothers in

a class. We have a psychological desire to socialize around and participate with people

who we perceive are like us. Curves, a company in over 85 countries, is a fitness and

weight-loss gym that solely focuses on women of all shapes, sizes, and ages (Curves

2013).

Social Proof – describes our mental shortcut of automatically placing high value on

something if a high number of people are also doing it (Cialdini 1993). If we walk by a

building, and there’s a crowd of people staring into the building, then we are most likely

going to check out what is going on. Similarly, if a certain wellness or wellbeing activity

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extremely popular, then many more employees will be attracted toward that activity.

Social proof is the psychological mechanism behind bandwagons, or people flocking

towards a ‘hot’ product.

Reciprocity describes the inclination that people have to give back to others those who

have given to us (Cialdini 1993). Think of the time when a colleague or friend did a

favor for you. The desire or invisible obligation to reciprocate increases the chances that

you will return the favor. For example, Team In Training, a program that raising money

for Leukemia & Lymphoma by participating in various endurance events like marathons

and hiking adventures, allows their participants to become coaches. Participants that

experience the rewards of becoming more fit through their programs, such as Team In

Training, are more likely to become advocates or coaches as a way of reciprocating the

great experience that the program gave them (Team in Training 2013).

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V. The Checklist

The Checklist is a set of questions to offer a system that focuses on fulfilling the

three main sets of behavior change research from section IV: Fogg Behavior Models,

Positive Reinforcement, and the Six Universal Principles of Influence. By testing the

wellness program against The Checklist, parties that are invested in employee benefits

and wellness do not have to solely wait on biometric results to assess the performance of

a program. Instead of waiting for annual biometric results, The Checklist allows wellness

program directors and wellness program innovators to catch the areas of improvements

EARLY. In other words, invested parties do not have to wait for one entire year to see if

a wellness program has been successful in creating behavior change based on biometrics.

As a complementary tool to biometric results, The Checklist can be used throughout the

year for assessing and tweaking wellness programs to constantly improve the personal

health of employees and financial health of the company. The checklist can be found in

appendix A and downloaded at www.behaviordesignchecklist.com.

SET 1: Fogg Behavior Questions

The following questions based on the Fogg Behavior theories provide a high level

assessment of wellness programs. Set 1 questions can be thought of as a “glance test” – a

snapshot of the wellness program. If wellness programs do not pass through the

following questions, then this thesis asserts that those programs need to be seriously re-

evaluated. Imagine red flags waving and emergency sirens going off.

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A. Motivation: Have Bob or Susan expressed desire to participate in the

program?

This question focuses on employees’ motivation – how much desire do they have to

perform the target behavior. Often times innovators, designers, and decision makers

come up with ideas that they get excited about. Then, they invest tons of resources into

their ideas, assume others will find them great as well, and then wonder why people did

not use them. Bob and Susan know that walking, running, or going to the gym will make

them healthier, but they do not want to do those things. Their motivation, their desire, to

perform the behaviors of walking and running is extremely low. As an innovator and

decision maker, help people do what they ALREADY want to do. What do they wish

they had more time to do? If it is spending more time with their family, then help them

do so through something also physically engaging!

B. Ability: Is it easy for Bob or Susan to actually engage in the target

physical activity program?

The response to the question focuses on ability factors. Meaning, how easy or difficult it

is for employees to actually engage in the target behavior – doing physical activity. Note

how many steps or things that employees must do BEFORE they are able to dance, go to

the gym, or participate in other physical activities. The number of steps is something to

be wary about because each step is an added layer of difficulty. For example, before

employees can participate in special wellness program activities, such as dance classes,

employees must complete several steps: discover that classes are offered, find a time that

fits in the their calendars, figure out appropriate dress code, find out where the building

is, find parking, walk to the building, find the room, start dancing. This is an example

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behavior sequence – the individual behaviors that finally lead up to the target behavior.

How easy or difficult is it to currently start attending dance classes?

C. Trigger: Is it clear how this program triggers Bob or Susan to

participate in the program?

A behavior does not happen if a trigger is not present because a trigger is the call to

action (Fogg 2009). Bob and Susan reading emails that prompt them to sign up for

summer classes is an example of a trigger. This trigger prompts them to take one step

forward to attending the dance class by establishing commitment of signing up. Imagine

in this email Bob and Susan also see that they can add the dance event onto their calendar

by clicking on the “Add to Calendar” URL. Again, this trigger moves Bob and Susan

one more step closer to actually attending the dance class. What triggers are in place for

each behavior in the behavior sequence to finally engage in the physical activity

program?

SET 2: Reinforcement Questions

The following reinforcement questions focus on a more granular level: when are

employees reinforced for participating in the wellness program. Specifically, this set of

questions will illuminate exactly when employees are reinforced and how often they are

reinforced. From the previous section IV on theory and research, it is very important to

know when and how often behaviors are reinforced because they indicate why certain

behaviors get stronger and other behaviors fade away.

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A. What forms of positive reinforcement do Bob or Susan experience

DURING their participation in the wellness program?

This question is important because it indicates when behaviors are being reinforced in the

process of engaging employees to be physically active. Positive reinforcement can be

monetary incentives, social appraisal, or anything that makes employees “feel good.” For

example, imagine the target behavior for Bob or Susan is to attend a dance class and the

reward is a monetary incentive of $10. Both Bob and Susan attend the dance class, and

they get the monetary incentive of $10 in their paycheck that comes 10 days later. The

reinforcement is coming too late. In this same example, there is another form of

reinforcement: social appraisal and inherent “fun” of engaging in a dance class. These

are great forms of reinforcement because they happen DURING the target behavior –

attending the dance class. By breaking down when reinforcement in relation to when the

target behavior is happening identifies if reinforcement is being applied at the effective

time.

B. Are positive reinforcement/rewards given at random frequencies

throughout the program?

This question is important because it indicates if the frequency of reinforcement is

optimal for the desired habit of engaging in physical activity wellness programs. Imagine

if Bob or Susan were given a random bonus incentive for attending Tuesday’s dance

class. They know that the random bonus will not happen every time, but the bonus

comes often enough that they keep coming (i.e., 1 out of 20 times). The reinforcement

does not have to be money; it can be different prizes, praise by the instructor, or

recognition from peers. This is the same psychological mechanism behind people

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uncontrollably gambling, checking emails, or checking social media. The important

takeaway is the FREQUENCY of reinforcement because making it deliberately varied

and unpredictable makes our brains crave the behavior more and more (Skinner 1958;

Miltenberger 2008).

SET 3: Influence Questions

The set of influence questions are saved for last because they will give the most granular

insights into physical activity wellness programs. Also just because a program scores

high in the following questions does not necessarily mean it will actually trigger the

target habit of participating in physical activity programs.

A. Authority: Is the program represented by a respected/admired brand or

figure?

Many studies confirm that people are very likely to do something if requested by a figure

that has authority (Cialdini 1993). If the CEO of company calls the wellness director and

requests that the director announces the new wellness program to employees, then the

wellness director is most likely to carry it out. Another example is if a famous person is

promised to be at the actual event, then people are likely to show up.

B. Commitment/Consistency: Has Bob or Susan made a commitment to

something small that relates to the goal of the target program?

People are also more likely to participate in physical activity wellness programs if they

can see the program aligning with their self-image and identity (Cialdini 1993). If

people’s thoughts and actions do not align, then what results is cognitive dissonance,

which is an uncomfortable experience that people learn to avoid. Framing the wellness

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program to align with people’s self-image and identity will make people more likely to

participate.

C. Similarity: Are there existing participants similar to Bob or Susan?

If there are existing participants who are similar to Bob or Susan, then they are more

likely to also participate in the wellness program. Similarity can be in terms of ethnicity,

income, gender, values, interests, etc. Sharing the fact that other there are existing

participants similar to Bob or Susan will make Bob or Susan more likely to participate.

D. Scarcity: Is a valuable aspect of the program deliberately hard to

obtain?

The principle of scarcity transcends race and time. People are attracted to things that are

scarce – rare – unique. If Bob or Susan is one of 10 participants in a premiere wellness

program, then they feel unique. People who think that a wellness program is truly unique

will be more likely to actually engage in the physical activity program. Limited

enrollment and offering a program only for a limited period of time are also examples of

scarcity.

E. Social Proof: Do Bob or Susan see this wellness program as popular?

Seeing that a wellness program is extremely popular is the easiest way to assess if

something is worth the time. This provides general social proof, which is powerful.

What is more powerful is if Bob or Susan’s colleagues and friends are participating in the

wellness program. Answering this question is important because it reveals how

recruiting and marketing campaigns are being executed—strategically focused or blindly

casting a net.

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VI. Case Studies: Physical Activity Wellness Programs Evaluated Using The Checklist

In this section, two programs from each partnered company will be discussed in

light of The Checklist, totaling six (6) different physical activity programs. Each

program was tested against The Checklist by the wellness manager either in person or

over the phone. Insights and data about the wellness programs were collected via in-

person interviews, Skype calls, and phone calls. Each program review includes:

a) A program overview;

b) A step-by-step experience from a participant’s perspective;

c) A screenshot of the program’s evaluation results based on The Checklist

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1. PB Healthy Rewards Program is a program to financially incentivize

all 20,000 Pitney Bowes employees. The goal of this program is to reward healthy

biometric values and/or health actions taken by employees with a 1 point to $1 dollar

system up to $500 per year. The specific health actions eligible for rewards depends on

the employee’s health insurance, such as Cigna and United Health Care.

When PB employees sign up for the PB Healthy Rewards program, they can earn

rewards points, which are tracked by both their insurance company and PB. For example,

Cigna gives 100 points for each of the following actions: achieving target biometrics,

working with a wellness coach, or improving 5% body weight. United Health Care

rewards employees via participation in a telephonic wellness course and their Change

One Plus program (some physical activity requirements are to track exercise, weight, and

food). Depending on which medical plans employees have, the monetary rewards are

paid monthly in their HRA or HSA (tax free), or annually in their January paycheck

(taxed).

Figure 6a. Screenshot of United Health Care’s Health Actions on Pitney Bowes website

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b. If Bob were a participant of Pitney Bowe’s Healthy Rewards program, he might

experience the following:

Bob reads an email saying that he can earn up to $500 dollars this year if he

improves his health. Bob already knows he is overweight and needs to start going to the

gym. Bob clicks on the email that links him to the Healthy Rewards program. He reads

that he first needs to take an online assessment through his medical plan with United

Health Care and get a biometric screening. He spends 20 minutes taking the online

health assessment test. Bob then schedules a biometric screening for next week at the on-

site Pitney Bowes clinic where he works. He receives his results the day after his clinic

visit and faxes the results to UHC on the form he downloaded from the Healthy Rewards

link.

Bob meets the biometric targets for his cholesterol, blood pressure and glucose,

but his Body Mass Index (BMI) of 26.1 is higher than the top of the target range. He

receives $300 for his in-target results, but nothing for his BMI. One week later after Bob

gets his biometric screening, he realizes he can earn 100 points ($100 dollars) if he

completes a free telephonic wellness course or achieves his target values in the upcoming

year. Because Bob already committed to go to his local gym with friends to lose weight,

he does not feel the need to enroll in any of the PB sponsored programs, such as Change

One PLUS or the United HealthCare Telephonic counseling. Bob goes to the gym

consistently for six months and drops his BMI to 24.8, which is in the 18.6 – 24.9 target

range. Because Bob has the Health Fund plan, he receives his monetary reward monthly

as earned in his Health Reimbursement Account (HRA).

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c. Checklist Results from Pitney Bowes Healthy Rewards Program

Figure 6b. Checklist Results for Pitney Bowes Healthy Rewards Program

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Pitney Bowes Healthy Rewards Program Breakdown Set 1: Glance Test (Fogg Behavior research)

A. Trigger: Is it clear how this program triggers Bob or Susan to participate in the program? Yes, triggers include word of mouth, on-site health fairs, and multi-channel communications, such as emails, brochures, and personalized letters.

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes, when participants complete a behavior from the list of eligible health actions, points are automatically logged by the medical plan of the employees.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? No, this is a program that is trying to capture all employees.

Set 2: Reinforcement Test (Reinforcement Research)

A. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? Yes, participants are being rewarded points for every healthy action that they take, which include taking the health assessment test, get a biometric screening and submitting results, and achieving target bio metric values. Participants can choose a monthly or annual payout.

B. Are you giving positive reinforcement/rewards at random frequencies throughout the program? No, participants do not receive rewards randomly.

Set 3: Influence Test (Cialdini Influence Research)

A. Authority: Is the program represented by a respected/admired brand or figure? Yes, the program has the backing of the Pitney Bowes brand.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? No, this information is unclear.


Yes, all Pitney Bowes employees are eligible for this program.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain? No, everything is of abundant supply for employees.


No, this program is not seen as popular because there are lower social interactions than desired.

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Pitney Bowes 2. Diabetes Control Program is an online program focused on assisting

employees and immediate family members with Type 2 diabetes. The program meets

weekly in a webinar with trained, certified instructors. Each session of the 7-week

webinar lasts for 30 minutes: 15 minutes of content and 15 minutes of Q&A. Slides and

recordings are given to participants each week. Also, there are weekly emails and a

discussion board for participants. Although this is program does not exclusively focus on

physical activity, it is included because it results in more physical activity in participants.

There was an increase of participants who exercised for 150+ minutes per week from

18% to 33% (out of 71 post-survey responses). Furthermore, 55% of participants

reported increased exercise. In the November – December offering, 167 employees

registered: 58% had type-2 diabetes, 21% had pre-diabetes, 15% wanted to learn how to

prevent diabetes, and 6% were family members with type-2 diabetes (diagram below).

Figure 6c. Graph Breakdown of Participants and Level of Type 2 Diabetes

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b. If Susan were a participant of Pitney Bowe’s Live Well with Type 2 Diabetes program,

she might experience the following:

Susan recently learned she has Type 2 diabetes. She reads an email about

wellness programs that Pitney Bowes offers. She searches the Featured Programs section

and sees a program for Type 2 Diabetes. She reads about the program offering;

specifically that it is during the workday at 12PM, during her lunchtime. She also sees the

program is recorded as she knows some weeks she might not available at noon. Based on

the registration instructions, Susan emails the contact to learn about the next program

start date.

One week before the start of the program, Susan opens an email about the details

of the live call. She marks the day on her Outlook Calendar for 12PM Wednesdays. For

the next seven weeks, she tries to attend all the weekly 30-minute calls. Susan misses

two meetings because of a lunch meeting and a work call. Each time she missed a call,

Susan checks the website for the records of the webinars. Furthermore, Susan reads the

discussion board responses to learn from other participants. Having learned about the

importance of tracking her glucose, she begins to check her glucose twice a day, learning

how what she eats and how much she exercises creates changes in her readings. She also

tries four of the new recipes she gets from other participants.

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c. Checklist Results from Pitney Bowes Live Well with Type 2 Diabetes Program

Figure 6d. Checklist Results for Pitney Bowes’ Live Well with Diabetes 2 Webinar Program

Pitney Bowes Live Well with Diabetes 2 Webinar Program Breakdown Set 1: Glance Test (Fogg Behavior research)

A. Trigger: Is it clear how this program triggers Bob or Susan to participate in the program?

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Yes, triggers include word of mouth, on-site health fairs, and multi-channel communications, such as emails, brochures, and personalized letters.

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes, participants send an email to the designated contact person. They attend the live weekly calls if possible; if not, participants can watch the recordings.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? Yes, participants pre-select themselves based on a self or family member diabetes diagnosis.


A. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? Yes, participants have the opportunity to participate in a live Q&A every week. This 15-minute Q&A section allows participants to be listened to and get feedback. It gives them the feeling of autonomy and validation that they are taking control of their health situation.

B. Are you giving positive reinforcement/rewards at random frequencies throughout the program? No, participants do not receive rewards randomly.


A. Authority: Is the program represented by a respected/admired brand or figure? Yes, the program has the backing of the Pitney Bowes brand.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? Yes, participants send an email to the contact person for program registration.


Yes, out of the 167 participants (58%) are also Type II diabetics. Others are trying to either prevent Type II diabetes or have a family member who has Type II diabetes.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain?

Yes, it is only offered during a specified time of the calendar year (i.e., November to December).


No, this program is not seen as popular because there is low participation in the online discussion boards. In addition, there is no visual proof (such as pictures of participants) or statistical proof on the program’s webpage.

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3. Cardinal Walk is an annual event that helps staff and faculty across different

departments participate in the 1.5mile campus walk across Stanford’s beautiful campus.

In 2012, 1500 members of the Stanford community participated in this event. May 10th,

2013 marks the 7th consecutive year of the event. It is one of Stanford BeWell’s most

popular events. At 12:10PM May 2013, hundreds of staff and faculty will participate in

this event starting at the Stanford Football Stadium (map of walk below).

Figure 6e. Map of Stanford BeWell’s Cardinal Walk 2013 (BeWell 2013)

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b. If Bob were a participant of Stanford BeWell’s Cardinal Walk, he might experience

the following:

Bob is an administrative employee in the English department. On an April

morning, Bob walks in to see a Cardinal Walk flyer posted on his office communal board

for events. He does not pay much mind to it. This happens every morning for the next

14 days. On the morning of May 10th, Bob reads an email saying that today is Cardinal

Walk, festivities starting at 11:30AM and the actual walk starting at 12:10PM. He walks

over to his buddies Alex and Kevin and asks them if they are going to Cardinal Walk.

When they say yes, Bob asks another question – if their supervisor will be participating in

Cardinal Walk. They tell Bob that the supervisor is also going. As 11:30AM creeps in

everyone begins to wrap up his or her work in anticipation of lunch break. At 11:45AM,

Alex and Kevin swing by Bob’s desk and ask if he is ready to go. Together, they walk to

Stanford Stadium from the Main Quad.

As they walk to the Stadium, Bob sees groups of different faculty and staff

members walking toward the same direction. Seeing so many other faculty and staff

participating makes Bob feel very good about doing his first Cardinal Walk. When they

arrive, tons of people are already there, music is playing, and everyone is having a great

time. At 12:05, Bob and his colleagues’ listen to Provost John Etchemendy give a short

speech. Bob thinks that it is great to have the support of such a high authoritative figure.

At 12:10pm, the walk officially starts. Throughout the entire walk, everyone is talking

with one another and having a great time. At the end of the walk, Bob made two new

friends Susan and Greg. When he gets back to the office, Bob thinks to himself he will

definitely be participating in next year’s Cardinal Walk.

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c. Checklist Results from Stanford BeWell’s Cardinal Walk Program

Figure 6f. Checklist Results of Stanford BeWell’s Cardinal Walk 2013

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Stanford BeWell Cardinal Walk Breakdown Set 1: Glance Test (Fogg Behavior research)

A. Trigger: Is it clear how this program triggers Bob or Susan to participate in the program? No, the triggers are a postcard that is sent in every Spring with several events, links and not-so-widely distributed flyers.

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes, it is extremely easy for participants to participate in this program because they just need to be present on the day of the walk.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? No, this program is marketed to all Stanford faculty and staff.


A. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? Yes, first 500 participants receive Jamba Juice gift cards as incentives, but all participants get to enjoy the festive music upon arrival at the walk. Participants also listen to a short speech by Provost Etchemendy.

B. Are you giving positive reinforcement/rewards at random frequencies throughout the program? No, there are no random reinforcement or rewards at the program level.


A. Authority: Is the program represented by a respected/admired brand or figure? Yes, Stanford Provost John Etchemendy and department supervisors are the “authoritative” figures that help make this program more influential.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? No, this information is unclear.


Yes, diverse groups of department supervisors and colleagues participate in the program so Bob or Susan would feel like they belong.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain?

Yes, there are a limited number of Jamba Juice gift cards for participants.

E. Social Proof: Do Bob or Susan see this wellness program as popular? Yes, this program is seen as popular because participants will see buy-in from their supervisors and fellow colleagues about the event.

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Stanford University BeWell 4. Wellness On Wheels is a program in which employees from eligible

departments can request a physical-activity class to be organized in their building. In

other words, the class is being brought to the team’s specific department building during

a normal workday. Physical activity classes include Yoga, Pilates, Zumba, and other

low-impact classes that can be organized in a conference room for 50-60 minutes. Also,

there is a minimum enrollment of 10 participants. Because this is a “satellite program”, it

allows flexibility for departments but also lacks oversight from the upper BeWell

management; thus specific numbers could not be found. Furthermore, this is one of

Stanford BeWell’s least active programs.

b. If Susan were a participant of Stanford BeWell’s Wellness on Wheels, she might

experience the following:

Susan describes herself as healthy and attends many of BeWell’s classes. She saw

the Wellness on Wheels program online. She thinks this is a great way to get her

department to be more healthy and active. Also she thinks it will be fun to have a Yoga

class in her department. She clicks the link to request a Wellness on Wheels class. Susan

starts filling out the form with basic contact information. She then sees that she needs to

coordinate a weekly time to have the class with her department. She skips this question

and continues with the form. Susan then tries to answer the class location questions

(address of building, room number, name of building). She has not chosen a room yet, so

she skips this question. She also sees that she has to clear this class with the facility

manager but does not even know who the facility manager is or how to contact him/her.

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The final question asks for the names and emails of at least 10 of her colleagues who

would be interested in participating.

She notes that she has to 1) get names and emails of 10 interested people 2)

contact the facility manager 3) figure out the class location 4) and coordinate a good

weekly time for her colleagues with an OK by her boss. She realizes this is more work

than it is worth and just invites her colleagues to the weekly yoga class that she goes to at

the on-campus fitness center.

c. Checklist Results from Stanford BeWell’s Wellness On Wheels Program

Figure 6g. Checklist Results of Stanford BeWell’s Wellness On Wheels

44

Stanford BeWell Wellness On Wheels Breakdown Set 1: Glance Test (Fogg Behavior research)

A. Trigger: Is it clear how this program triggers Bob or Susan to participate in the program? No, the triggers are emails, hard-to-find links on the Stanford BeWell website, and in the Health Improvement Program class guide.

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes and no, but mostly no. Participants simply express interest in specific classes and participate on the day of the 50-60 minute session. This is easy. The hard part is to find a “class champion.” This class champion answers 23 questions on a form. Before answering all the questions, this employee needs to find 10 interested people and collect their names and emails; find a weekly room to have the class; and clear it with the facility manager.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? No, this program is not doing well.


A. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? N/A.

B. Are you giving positive reinforcement/rewards at random frequencies throughout the program? N/A.


A. Authority: Is the program represented by a respected/admired brand or figure? Yes, the support of the department and BeWell itself lends authority.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? No, this information is unavailable due to the lack of oversight.


Yes, department-exclusivity allows Bob and Susan to feel like they fit in.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain? Yes, only departments who are able to get at least 10 employees to sign up are eligible.


No, this program is not seen as popular.

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5. GapFit 5K Run is a monthly 5K run/walk for all Bay Area employees. On

average 20 – 30 employees out of 300 employees participate in this event. Most

participants are female and are X or Y Generation. GapFit 5K Run always starts toward

the end of the day at 4pm for convenience purposes (i.e., not returning to work all

sweaty). All employees receive a calendar tap in their email inboxes about GapFit 5K

Run (example below):

Figure 6h. Screenshot of a “Calendar Tap” for GapFit 5K Run

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b. If Bob were a participant of GapFit 5K Run, he might experience the following:

Every time Bob steps into the elevator, he sees different ads for company events.

For the past two weeks, he sees the GapFit 5K Run ad in the elevator. He is interested

but does not know if he is free that day. One day Bob sees a “Calendar Tap” email from

his senior team leader: it shows the details of the event and more importantly the

day/time of the event. He checks his calendar and sees that he has free time. Bob

immediately clicks the “Add to Calendar” button. Bob knows that his senior team leader

is leading this event but wonders who else in his peer group will be participating. He

starts asking around and learns that the majority of participants will be female colleagues.

Bob knows several of them, such as Joy, Martha, and Betty, so it does not deter him;

however, he think a couple of more guys would not hurt.

On the day of the run, they all set out and have a great time running through San

Francisco. New friends are made and motivation for doing this again is high. The next

time the GapFit 5K Run was organized, it was not publicized as much. By that time, Bob

had forgotten to keep tabs on it and did not participate again.

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c. Checklist Results from GapFit 5K Run Program

Figure 6i. Checklist Results for GapFit 5K Run Program

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Set 1: Glance Test (Fogg Behavior research) A. Trigger: Is it clear how this program triggers Bob or Susan to participate in

the program? Yes, organizers send a “calendar tap” to all employees (so that employees can RSVP and see the specific details of the event). Furthermore, there are flyers on the ad space in elevators because “employees don’t do anything in the elevator.”

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes, the Gap Fit Run is always at the end of the day at 4PM. Participants do not have to worry about showering and can just go home.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? No, this program is not doing too well with only 20 out of 300 eligible participants.


C. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? N/A

D. Are you giving positive reinforcement/rewards at random frequencies throughout the program? N/A


A. Authority: Is the program represented by a respected/admired brand or figure? Yes, the senior leader of the team acts as the “authoritative” figure.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? N/A


Yes, most participants are Gen Y and Gen X, majority of them being female.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain? No, anybody could participate.


No, this program is not seen as popular due to inconsistent marketing campaigns.

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Gap Inc. 6. Tai Chi Offering is a program that brings a Tai Chi instructor into the

department itself during the workday. It allows employees to be physically active without

being too inconvenient (i.e., change into different clothes and sweating). The Tai Chi

class is done outside in the courtyard so employees can watch from their desk or pass by

on their way to lunch. Although the number of participants is low, those who do

participate come “religiously.” Furthermore, those same participants always try to

invite others to the event. Videos of all 64 Tai Chi movements are recorded for

participants to practice outside of class.

b. If Susan were a participant of Gap’s Tai Chi Offering, she might experience the

following:

One day Susan hears from her good friend Rebecca about a weekly Tai Chi class

offered in the mornings and during lunch. Susan tells Rebecca that she knows what Tai

Chi is but is not really into “that kind of stuff.” Susan sees that Rebecca is not deterred –

“I’ll ask you again next week!” Susan thinks that Rebecca’s comment is nice, but she

probably will forget about it by next week.

Next week comes around and Susan is delightfully surprised with Rebecca asking

her to come to Tai Chi again. Susan declines again, but this time Rebecca tells her to try

checking out some of the Tai Chi information online. During her lunch-break, she sees

Rebecca and several other colleagues enter the conference room to do Tai Chi. Susan

watches for a couple of seconds, seeing them get organized. Susan looks back at her

computer and finds the Gap Tai Chi Offering description. This time she is seriously

considering trying it out. Susan realizes she just finished her lunch as well and it has only

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been 20 minutes into the class. Instead of waiting until next week, Susan musters up her

courage and walks into the class.

Susan apologizes for interrupting and says it’s her first time. The instructor

welcomes Susan and makes her feel very comfortable. Susan then catches Rebecca’s eye

and smile. Susan smiles back. For the next 40 minutes and many consecutive weeks

later, Susan enjoys Tai Chi.

c. Checklist Results from Gap Tai Chi Offering

Figure 6j. Screenshot of a “Calendar Tap” for GapFit 5K Run

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Set 1: Glance Test (Fogg Behavior research)

A. Trigger: Is it clear how this program triggers Bob or Susan to participate in the program? Yes, Tai Chi is included in the email that goes out for all offerings. In addition, loyal participants always encourage their colleagues to attend via word of mouth.

B. Ability: Is it easy for Bob or Susan to engage in the target program? Yes, Tai Chi is offered only at convenient times (morning and lunch sessions). Participants can stay in their work clothes as well.

C. Motivation: Have Bob or Susan expressed desire to participate in the program? No, this program has the lowest number of participants.


A. Do Bob or Susan receive positive reinforcement DURING their participation of the program (on the program level)? N/A

B. Are you giving positive reinforcement/rewards at random frequencies throughout the program? N/A


A. Authority: Is the program represented by a respected/admired brand or figure? No, the instructor is not well known and also has no ties to the company.

B. Commitment/Consistency: Has Bob or Susan made a commitment to something small that relates to the goal of the target program? Yes, participants have to practice Tai Chi movements outside of the class in order to get better.


Yes, demographics are pretty similar in the entire company.

D. Scarcity: Is a valuable aspect of the program deliberately hard to obtain? Yes, there is limited enrollment of about 20 participants.


No, the program is not that popular.

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VII. Insights & Recommendations

With the aim of designing better wellness programs to increase participation and

efficacy, the following insights and patterns were realized. This section will cover

insights as revealed by the studied programs, as well as suggestions for future design

iterations. Each insight will be broken down into three parts:

a. Example of the program

b. Related Research

c. Suggestions for future design iterations

Positive reinforcement at random frequencies are weak on the program level.

a. During a webinar or a Yoga class, great instructors will praise participants on

their efforts. This is positive reinforcement, but on the individual level. On the program

level, positive reinforcement at random frequencies is fairly non-existent throughout all

programs. None of the six programs above provided positive reinforcement at random

frequencies on the program level.

b. Random, unpredictable reinforcement is essential to creating strong behaviors

(Skinner 1958). In behavioral research, this is called variable scheduling. Wellness

managers and designers can vary reinforcement by tweaking two things: 1) the

frequency of the desired behavior performed, or 2) the frequency of time passed

(Miltenberger, 2008). Playing lottery scratchers is an example of varying the number of

times a behavior needs to be performed. The number of times a person plays and wins

can vary. A wellness example would be giving out coupons to WholeFoods every 2nd,

then 4th, then 10th time a participant comes to the Yoga class.

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Varying the frequency of time passed is the second way to give positive

reinforcement randomly. A program would reinforcement the target behavior based on

different time intervals: the first reinforcement would be given after 2 minutes has

passed; then the reinforcement would be given after 6 minutes has passed; next,

reinforcement would be given after 3 minutes. This way, positive reinforcement is

unpredictable. Watching sports like basketball or football are examples of tweaking time.

The frequency at which points are scored is randomly throughout the duration of the

game. This random frequency of time reinforces the behavior of watching. A health

wellness example would be handing out WholeFood coupons to stationary cyclists every

2 minutes, then 6 minutes, 3 minutes, and so on. See Appendix B for a graph that

illustrates the effects of the two types of variable scheduling).

c. Program managers in charge of the Stanford’s Cardinal Walk could ask Provost

Etchemendy to use a horn that sounds at different time intervals throughout the 1.5mile

walk. Every time this horn is heard, everyone smiles, laughs, and yells the Cardinal

Walk cheer. Positive reinforcement can vary in frequencies of behavior or time.

“Calendar Taps” is a strong trigger because it increases commitment.

a. At Gap Inc., employees receive “Calendar Taps” in their email inboxes. A

“Calendar Tap” is a hot trigger (call-to-action) in the form of a conference call or

calendar invite that contains event information and an RSVP option. For example, a

Google Calendar invite allows participants to see the date/time and optional information

of the event. It also allows invitees to accept or decline the Calendar invite. (See section

6, figure 6a for a screenshot of Gap Inc.’s “Calendar Tap.”)

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b. Dr. Fogg’s research finds that behaviors will only happen if there is some type of

trigger (call-to-action) simultaneously present with motivation and ability to do the

behavior (Fogg, 2009). The first reason why “Calendar Taps” are great triggers is

because it provides essential information for a person to make a decision – to attend or

not attend. This increases the ability factor for the employee, by simplifying the decision

process. Second, it automatically sets up the employee to easily RSVP to the event. If

employees RSVP to attend, then they are more likely to attend because of the influence

principle of commitment/consistency: employees who commit to the GapFit Run will be

more likely to stay consistent with their previous commitment of attending (Cialdini et al.

1999).

c. Program managers might add a layer of social proof in the Calendar Tap feature.

A follow-up Calendar Tap is sent every time 3-5 people who RSVP “attending.” Each

time will create more social proof around participating in the GapFit 5K Run events.

Any layer and combination of Cialdini’s principles of influence can be added to this

“Calendar Tap” trigger.

Elevator Ads are great triggers if employees can act in <7 seconds.

a. Gap Inc. has elevator ads for their health events. These elevator ads share

information about wellness offerings and events. Most advertisements, such as these, are

simply educational material: giving out details of events and information of how to

participate in something, hoping that readers will remember the offering in the future. A

more effective advertisement is to solicit an extremely small action from the potential

participant. This action needs to be so small that it can be done in less than the elevator-

ride time. The quicker the action can be completed the better.

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b. This extremely small action can be seen as an example of the influence principle –

commitment/consistency. This extremely small action, which acts as the commitment,

may increase the likelihood of employees taking a closer step to perform the end-target

behavior, such as joining Gap’s Tai Chi class or enrolling in Pitney Bowes webinar for

Type-II diabetes. Arizona Psychologists Goading et al. calls this the “foot-in-the-door”

effect (2001). They found that people who strongly desire to be consistent with their

comments would comply with this process: begin with a small request and then advance

to larger, related requests.

c. Program managers could place Elevator Ads interest sheets in the elevator.

Attached to the interest sheet will be a pen for employees to quickly write their name on

the sheet. This can be immediately applied to Stanford BeWell’s Wellness on Wheels

offering or even Pitney Bowe’s Live Well Diabetes Program. This design can also be

used to test new wellness program ideas, or to survey employees on issues (i.e., “Do you

know anyone who does program X?”). The following larger requests could be reading a

related article, talking to a coach, or participating in the actual program.

Buy in from high-authority superiors and respected colleagues are a must.

a. Programs with the highest participation have either a director supervisor/authority

figure endorsing the program. For example Stanford’s Cardinal Walk had Provost

Etchemendy. GapFit 5K Run (in March 2012) had Art Peck and Mark Breitbard,

President of Growth, Innovation, and Digital and President of Gap North America,

respectively.

b. Getting buy-in from high-authority superiors takes advantage of Arizona

Psychologist Dr. Robert Cialdini’s authority and social proof principles. Sometimes

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getting buy-in from high-authority superiors is not possible. The next buy-in can be from

“peer influencers.” This takes advantage of Cialdini’s principle of social proof in

combination with the six sources of influence. Peer influencers and high-authority

figures that simultaneously use four or more sources of influence are 10x more likely to

get results (MIT Sloan Management 2008).

c. Program managers could recruit “peer influencers” to participate in programs

because they will lead changes in the rest of their fellow employees. These “influential”

employees can make others follow them (Shirey 2008). Imagine the effects of getting

peer influencers to participate in any of the studied wellness programs studied.

Appendix C shows the model for the six sources of influence, which can explain how to

be and identify an influencer.

Limited enrollment should be initially used for any new or weak programs.

a. Gap Inc.’s Tai Chi Offering is an example of implementing limited enrollment.

Making a program offering have limited enrollment creates scarcity. This will increase

motivation and desire to participate in the program (Cialdini 1993). There is also a long-

term cost benefit for limiting enrollment in programs, specifically with potentially weak

programs.

b. In the Journal of Economic Psychology, Verhallen discovered two insights about

“Scarcity and Consumer Choice Behavior.” People who are attracted to the offering will

see scarcity (in this case limited enrollment) as desirable; however, if people are not

attracted to the offering, then they avoid choosing the scarce offering. (1982)

c. The recommendation is to always limit enrollment of new programs or weak

programs (low participation). Limiting enrollment of programs will keep the program

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size, staff, and financial costs low. During this time, many iterations and tweaks can be

made to better the program at the cost of a few employees. Throughout this period, other

employees will have started a line to get into this program. When the program is refined

at a level ready for the masses, directors can confidently open up the program to more

employees. This way, programs do not waste masses of potential loyal participants in

mediocre programs.

There is too much text and not enough visual social proof on websites.

a. All webpages about a specific offering are predominately text. There were little

visuals of participants associated with each program.

b. Research states that often times pictures of humans are more positively received

(Cyr et al. 2009). Furthermore, photos of people increase the trustworthiness of websites.

Sometimes, however, adding human photos can negatively affect the viewer experience

(2009).

c. A suggestion for iteration on wellness websites is to add photos of real

participants who did the specific activity. To determine if adding a human photo will

positively or negatively affect the conversion rate, run an A/B split test. Also, the

pictures used must be “real” – not stock photos (Cyr et al. 2009).

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VIII. Conclusion and Future Directions

The Behavior Design Checklist serves as a research-driven, physical activity

wellness program evaluation tool. It was derived to arm corporate wellness program

managers with a means to better examine their current program offerings. The Checklist

is the first systematic method for assessing the efficacy of physical activity wellness

programs before managers invest/launch programs. The works of three main

psychologists support The Checklist: Dr. B.J. Fogg of Stanford University, Dr. B.F.

Skinner of Harvard University, and Dr. Robert Cialdini of Arizona State University.

Furthermore, The Checklist has been tested on six different physical activity wellness

programs across three partnered companies - Pitney Bowes, Stanford University BeWell,

and Gap Inc.

This thesis further strengthens the connection between Behavior Design and

physical activity wellness programs by shedding light on ways to systematically think

through the psychology behind the design of a program. While several more rounds of

testing is needed to validate The Checklist, one next development step could entail

measuring the difference in program participation and retention in a split test. The

second step would be to use The Checklist as a starting point in a process for rapidly

testing improvements. Imagine an entire process/pipeline that allows wellness managers

to go from The Checklist, work with an external team dedicated to rapidly testing new

ideas, and see improvements as fast as a startup.

The purpose of The Checklist is to improve physical activity wellness program

design in order to optimize lasting behavior change in employees. Eventually, The

Checklist can be expanded into a tool that has a scale-point system for each question. For

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example, “This program received a 5 on trigger. How might we get it to an 8?” This

way The Checklist can provide an even more detailed feedback loop for wellness

managers to iterate on their programs. Wellness program managers need to be guided in

ways to design for healthy habit development, and the The Checklist is, as a tool, a great

first step for doing just that.

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IV. Appendices Appendix A. The Behavior Design Checklist

For a printable version, go to: www.behaviordesignchecklist.com

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Appendix A cont. The Behavior Design Checklist

Right-hand corner text says:

For a printable version, go to: www.behaviordesignchecklist.com

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Appendix B. Schedules of Reinforcement

Varying frequency of behavior needed to result in reinforcement = Variable Ratio

Varying frequency of time needed to result in reinforcement = Variable Interval

Schedules of Reinforcement in B.F. Skinner’s 1958 “Teaching Machines”

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Appendix C. The Six Sources of Influence

(MIT Sloan Management Review 2008)

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