Design for behaviour change

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Transcript of recording with Roxana Barbu – generated automatically by HappyScribe which means it will be about 80% accurate – if you spot confusing errors, please email The timestamps are included to help you jump directly to a point of interest.


[00:00:06.170] – Roxana Barbu

Hi, everyone, I’m Roxana Barbu, a cognitive double specialist at Macadamia Technologies, both at Macadamia and in my previous roles. I’ve always been drawn to projects with a health care component. I am drawn to their complexity and humbled to be a part of someone’s intimate behavior change journey to a better health outcome today. I’d like to start with a confession and then I’ll touch upon the famous three hour model. The rest of the time I’ll focus on underestimated aspects of behavior change specifically.


[00:00:43.660] – Roxana Barbu

Specifically, we are going to talk about barriers. We’re going to talk about the psychology and complexity of behavior change, as well as too many surprises. The fact that successful digital solutions should empower a person to be an independent. So here’s the understatement of the month, behavioral change is hard. We all know this intuitively, otherwise would be walking around being the best versions of ourselves. So not too long ago, I was juggling a full time job, a part time teaching one, a full time C and of course family and health.


[00:01:36.320] – Roxana Barbu

As you can imagine, there wasn’t much time left for actively changing behaviors. Truth be told, coffee and pizza were my best friends at the time. But I was convinced that the second I graduate and I stopped teaching and I have less on my plate, I can instantaneously and successfully start acting on my journey to a better health. My list was so long. Drink more water than coffee, improve my physical health, achieve a better sleep routine, pick up hobbies where I left them before my schedule became so tight and the list goes on and on.


[00:02:18.720] – Roxana Barbu

Needless to say, it did not take long after graduation to realize that making all of these changes was not going to happen overnight. It’s been close to a year now, and I am happy to share that I finally checkmark most of them. However, that didn’t happen until I acknowledged that one. It is hard to is going to take time. And three, lack of time wasn’t the only barrier I had to worry about. So really, the best way to summarize this, at least for me, was that the transition from intervention to successful, long lasting behavioural change, though, is paved with good intentions.


[00:03:08.220] – Roxana Barbu

It has twice as many barriers. And really having all this behavior change knowledge that I do have helped, but not in that initial state where I was convinced I can do it and forget about the barriers myself. So really, why do we sometimes forget to acknowledge that behavior change is hard? Empire, I think it’s because if it were in isolation and in perfect conditions, this three hour model, it’s so beautiful in its simplicity. So let’s go over this model together, ramyun routine, Ruwart reminder is that a never ending alarm that tells you what to do or perhaps the voice of someone who cares about you, telling you time and time again do this or do that routine is what happens if we do listen to the reminder.


[00:04:11.000] – Roxana Barbu

We end up successfully engaging in a routine. And this is really crucial because repetition is key to habit formation. Grillwork could literally be the icing on the cake or anything. That reminds us we did good. It could be material like the cake itself, but it could also be more personal and internal, like just having a great night’s sleep after a long nature walk for someone who usually finds it challenging to fall asleep. This three hour remind routine reward seems really straightforward.


[00:04:49.050] – Roxana Barbu

So, again, what are lies the problem? The biggest one, as far as I can tell, is that this three hour model works if and only if without a fail. We follow through with the reminder and successfully engage in the behavior change we’re trying to address. So the path from reminder to routine goes perfectly. However, if you’ve ever snooze your alarm button, you know that’s not the case. So here is a poll. How long do you think it takes to achieve long lasting behaviour change on average, five days, 21 days or sixty six days?


[00:05:40.480] – Roxana Barbu

What would your answer be, feel free to type this in the chat box, five days, 21 days or sixty six days. So I’ve done this survey time and time again and too many fall prey to the 21 day myth, on average it takes about sixty six days, but most importantly, it may be as fast as 18 days, but can take up to two hundred and fifty four days. I’ll say this again, anywhere between 18 days, up to two hundred and fifty four.


[00:06:20.990] – Roxana Barbu

That’s a range of less than three weeks to close to nine months. This is as good of a hand as we can get that there’s a lot more going on than the straightforward, beautiful three hour model. So then what are some of the factors that lead to this variability? So to start with, outside of that perfect silo, there’s barriers and these barriers work against us and make behavior change so much more complex. There’s also advantages or support the factors that facilitate behavior change.


[00:07:03.790] – Roxana Barbu

But let’s focus on the barriers, because those are the ones often overlooked. Barriers can be anything. Some are individual to each person, others are shared across groups of people, whether it’s anxiety, financial stability, the pandemic and the lockdown, the type of motivation, be it internal or external. So intrinsic or extrinsic to ourselves, lack of work, life balance and lack of social support, environmental changes, stress. You can tell I’m running out of breath here, but really there’s so many more.


[00:07:44.980] – Roxana Barbu

These barriers may be the culprit, explaining why someone doesn’t make it from the reminder step to establishing that routine. So he the easy stuff one for practitioners is to acknowledge the existence of these barriers and to go ahead and start identifying them. This can be done by identifying barriers at the personal level and or with the beautiful collaboration between us and data science. He could be personalizing or individualisation at each person’s level. So let’s walk through a few examples, if we think of the pandemic as a barrier, this one that we’re all sharing at a global level, the building I was working in, I was living in when the when the pandemic started, there was a group of women, seven women.


[00:08:43.260] – Roxana Barbu

They all were trying to manage their diabetes condition. They were using a digital health app. And that app was giving them suggestions how they can go ahead, what can they do to improve their physical health. And the suggestions that they agreed on as a group were aqua fitness and walking together as a group. And whenever the season permitted, they all had the common plots in our patio and work together on that. So they were using this health app to both monitor their sugar levels to get inspiration, what sort of physical activities they can do and also to track their physical activity.


[00:09:31.330] – Roxana Barbu

The problem was when the pandemic started, all of a sudden, as you can only imagine. Going to the community pool for Aqua Fitness, going together for a walk and even gardening as a group in a common plot, those were no longer feasible options. The ad continued to ask them to track their sugar levels, to track their physical activity, but where it failed, it no longer provided them examples of physical activity that were appropriate in light of this environmental change barrier.


[00:10:11.770] – Roxana Barbu

So easy is step one would have been acknowledged there, there has been a variable and environmental change that relates to this. These options no longer being feasible, once you acknowledge that all someone have to do is revise the list of options and include things like if someone has Internet, just go ahead and sign up for these group workouts and do it in your own living room. But they fail to do that. So in this example, the barrier was clear was the pandemic, we’re all aware of it, but other times barriers are not immediately clear.


[00:10:56.460] – Roxana Barbu

So there can be cases where the barrier is not external in the environment, but it’s specific to the person. So if we think of multiple sclerosis as someone with multiple sclerosis, advances in their medical condition, their motor skills decline. So from a digital health perspective, if you do that study with people with multiple sclerosis in their early stages, you will see that maybe they love the app and it’s really effective. Unfortunately, if the study is not repeated longitudinally at some point, a lot of the tasks that involve fine motor skills, even like check marking or typing or drawing a clock, which is a common activity in multiple sclerosis, are no longer feasible.


[00:11:48.930] – Roxana Barbu

So digital health apps need to develop this. First, the process of acknowledging that there’s barriers, external or internal, that people’s needs change over time and then they need to track these and capture them and respond to them to be successful. So now that we’ve gone over all these barriers that affect all of us to some degree, digital health apps also need to account for the complexity of the psychology of behavior change. So, as I said earlier, behavior change is a journey from having a goal or intention, a desire really to change something to achieving long lasting behavior change.


[00:12:42.550] – Roxana Barbu

So this slide is particularly busy, is one of my least favorite slides, but really the reason it is so it’s because it barely begins to scratch the surface of how complex behavior you really is. So let’s go through the journey a little bit together. Once we initially have that desire or motivation, we’re going to have a motivation, right, so it could be intrinsic or extrinsic if the motivation is intrinsic, is fueled from within, it’s really personal to us.


[00:13:21.190] – Roxana Barbu

We’re fully in it and we’re fully dedicated. But what about extrinsic motivation, which is really common in digital health apps yet unaccounted for? So a scenario here is someone went to the doctor, they got diagnosed with something and they need to embark on a behavioral journey. They need to start the treatment immediately because otherwise the risks are huge. They need to do this before they even have the chance to even come to peace and acknowledge and accept and learn about their diagnosis.


[00:13:56.830] – Roxana Barbu

So health apps have the really difficult job of dealing with behavior change even when there is no intrinsic motivation. And this kind of translates in the types of rewards that people respond to, if the motivation is intrinsic, you’ll respond to respond to motivational quotes or things like that or just tracking your own performance. Whereas if it’s extrinsic, it takes a lot more and stronger rewards, many times external to really determine someone to keep going. So that’s perhaps the first most important step to worry about.


[00:14:40.650] – Roxana Barbu

Then there’s these two phases. So on one hand at the beginning when we start. Everything is really chaotic, we miss those reminders, we don’t engage in that routine, it’s difficult. We may do it two days and then something happens and we fail and so on. In these phases, we have high cognitive effort cost. So it’s just really difficult to us. And that’s where we talk about the taking from eight, two hundred and fifty four days.


[00:15:11.050] – Roxana Barbu

But at some point there is a transition point and we do achieve this automatic low cognitive effort behavior. So the app needs to acknowledge the transition. If we were successful, we don’t we no longer need frequent rewards and frequent reminders and maybe we’re ready to move on to a higher level of behavior change or a different goal that we want to achieve and so on. So apps need to be sensitive. And one way to do this is to really pay attention to people’s performance and tracking and analyze that, to understand where they are in that 18 to two hundred and fifty four journey.


[00:15:53.020] – Roxana Barbu

And in between those two phases, I they in that chaotic performance where it’s really, really hard or fast, the transition point. And they were successful. So really taking all of this together that you have it is automatic once we pass that transition point is effortless with a low cognitive cost and it’s really app independent. So before we end, I would like to tell you what I mean by an independent, because this component is really under lock. And how can one achieve that?


[00:16:35.880] – Roxana Barbu

So let’s look at a concrete example of how a nap can support the user in becoming an independent. So the easiest way if the think of the reminder component, so many of the times we rely on apps and our phones to give us that reminder, whether it is to take our pill or just to engage in the routine itself and so on. But Fabulous, for example, provides a wonderful way of taking this reminder outside of the app and placing that burden onto the environment itself.


[00:17:13.530] – Roxana Barbu

So what fabulous does? It advises the person to leave sticky notes around the room. So in my case, when I signed up as a user, I wanted to drink more water than coffee as I already confessed. So that led to me putting sticky notes everywhere on my fridge, on my computer desk, by my bed, on my bathroom mirror to remind me first thing in the morning. And those sticky notes then prompted me to have water bottles in all those places.


[00:17:46.770] – Roxana Barbu

And I’m a big fan of cold water right from the fridge. So then it was just everywhere. There’s always water balloons around me now. So taking it outside of the app into the environment, it kind of moves from being a purely a reminder to really serving as external cues and modification that is conducive to behavior change. So many kind of respond to this like, well, we want people to use the apps, yes, we do, until they are successful.


[00:18:25.970] – Roxana Barbu

There’s no reason why a successful behaviour change has to be app dependent, particularly in digital health, where the focus really is the person’s outcomes as opposed to long term engagement or gamification or entertainment. So that was quite a bit so our main takeaways are just that the three hour model reminder, routine reward is only the beginning and behavior change is really complex. Whether we’re thinking of those barriers or we’re thinking of the psychology of habit formation, habits are not formed in style and we need to account for those barriers to identify and respond to that.


[00:19:15.210] – Roxana Barbu

And last but not least, app independence. So a true habit formation doesn’t have to be app dependent. There is a point where we pass that back to the user into their environment to support them even further. Thank you so much and please do not hesitate to contact me for any future questions that we may not get the chance to reach and Q&A and looking forward to your questions.