Effective communication is an essential component in the mix of strategies used to effect behavior change in regard to healthy eating. But are nutrition educators using all the behavior change tools? Are we really communicating effectively? Is our communication passionate enough and inspired enough to be heard? How do we increase the likelihood of improving healthy nutrition behaviors? With so many voices and choices out there in so many mediums (i.e. social media, grocery and food packaging advertising, television commercials, radio, etc) we have constant competition. This topic is sure to get nutrition educators thinking about how they currently communicate and to consider new avenues and strategies for their programs.

1. Disruption of the 'Usual' -
Rethinking Behavior Change
and Communication in Nutrition
Education
R. Craig Lefebvre, PhD
chief maven, socialShift
Lead Change Designer, RTI International
Research Professor, Florida Prevention Research
Center at the University of South Florida College of
Public Health

2. Theory: The Frames We Use to
Understand and Solve Problems

3. The Power of Theory
• Explains how or why things are related
• Guides us to identify what’s important
• Suggests what questions to ask
• Creates assumptions about what we
should do about the problem
• Proposes what objectives to set
• Determines how we measure success

4. Changing Scales of
Reality
• The Frame Problem – It is
impossible to know all the potentially
relevant facts and determinants of a
puzzle, given the overwhelming
number of possibilities and
combinations of variables.
• The Micro-Macro Problem – Our
desire to achieve macro outcomes,
ones that involve changes among
large numbers of people, or in
society as a whole, are driven by the
micro actions of individuals; changes
at different levels of organization are
emergent, not simply an adding up
of the components.
“Social change programs need to
consider more than one scale of
reality at a time.”

5. Micro-Macro Gap
X 85 bn ≠

6. Sources of Program
Failure
• Insufficient intervention resources
• Nonsupportive social and political
environment
• Measurement and evaluation
design
• Wrong theory used to understand
problem and develop strategies

7. Where Theory Can Make a
Difference
• What problem to
tackle - and how
• What the program
objectives should be
• Which priority
audiences to choose,
and how to
characterize them
• What questions to ask
in formative research
• Which approaches
may be the best to use
with specific groups of
people
• How to best promote
behaviors, messages,
products, and services

8. Theories of Change
Stages of
Change
Health Belief
Model
Social-
Cognitive
Theory
Diffusion of
Innovations
Social
Networks
Precontemplation Susceptibility Reciprocal
determinism
Relative
advantage
Opinion
leaders
Contemplation Severity Behavioral
capability
Compatibility Groups
Preparation Threat Expectations Complexity Adding or
removing
members
Action Perceived
benefits
Self-efficacy Trialability Bridging
groups
Maintenance Perceived
barriers
Observational
learning
Observability Rewiring
groups
Decision balance Cues to action Reinforcement Network
weaving

9. The Rational Person

10. The New Model

11. The New Model
Rational
Deliberate
Forward looking
Gets loss in
analysisEmotional
Instinctive
Immediate needs
Lazy

12. Behavioral Economics
The study of the allocation of psychological
(mental) resources to decision-making and
behavioral choices.

13. Personal Biases
• Loss Aversion - People are more averse to losing things than they are
inclined to gaining things.
• Status Quo Bias - One of the best predictors of our future behavior is our
current behavior. This is because inertia is so powerful.
• The Dual Self - People have competing preferences, with different
preferences dictating different actions at different times.
• Attention Constraints - People get distracted. Simply paying attention to
one’s goals is often half the battle in reaching them.
• Defaults - People make passive choices based on how the choices are
presented to them.
• Resource Slack - In planning for the future, people realistically assumed
that money will be tight, but they expect free time to magically materialize.

14. Scarcity is the fundamental
economic problem of having
seemingly unlimited human
wants and needs in a world of
limited resources.

15. Scarcity

16. Bandwidth

17. Limited Resources
• Scarcity of cognitive capacity –
• Cognitive resources available to people at any
moment are limited and can be depleted by being
used for other activities. So increasing the cognitive
demands of nutrition programs may in fact be
making them less likely to succeed.
• Rules-of-thumb; simplify Choices.

18. Limited Resources
• Scarcity of self-control –
• Think of self-control as a psychic “commodity” of
which we have a limited stock, so that using some up
for one task (“continuing to exercise when you want
to stop”) depletes the amount available for other
tasks (“resisting the extra cookie after your
workout”).
• Defaults; Time Management skills; explicit
Commitments

19. Scarcity

20. Tunneling

21. Limited Resources
• Scarcity of attention –
• Think of attention as another precious commodity –
people do not have unlimited attention and may not
pay attention to the ‘right’ things – they are busy
paying attention to others.
• Prompts and reminders; Incentives.

22. Scarcity

23. Multi-Tasking

24. Limited Resources
• Scarcity of understanding –
• People’s mental models of how the world works (or
what makes a food ‘healthy’) may be incomplete; not
all underlying causal relationships are correctly or
accurately understood.
• Tailoring of messages to existing mental models.

25. Scarcity & Bandwidth

26. Framing Effects, Social
Comparisons, Norms
• Link reminders to a specific goal they have set.
• People are more responsive to what they will lose
than what they will gain by (not) doing something.
• Compare what people do with their peers.
• Most individuals make efforts to conform to what
they perceive the social norm to be.

27. Behavioral Economics:
So What?
Stop berating people for not being responsible and start
to think of ways instead of providing the poor with the
luxury that we all have, which is that a lot of decisions are
taken for us. If we do nothing, we are on the right track.
For most of the poor, if they do nothing, they are on the
wrong track.
– Esther Duflo
“
”

28. Diffusion on New Ideas and
Behaviors

29. Characteristics of Segments
Innovators Early
Adopters
Early Majority Late Majority Laggards
Venturesome Respect Deliberate Skeptical Traditional
High tolerance
of risk
Opinion
leaders
Very local
perspective
Sensitive to
peer pressure
and norms
The
traditionalists –
tried and true
Fascinated
with novelty
Well-
connected
socially and
locally
Very engaged
in peer
networks
Cautious Keepers of the
wisdom
Willingness to
travel to learn
Resources and
risk tolerance
to try new
things
Rely on
personal
familiarity
before
adoption
Usually scarce
resources
Near isolates
in their social
networks
Seen as
mavericks, not
opinion
leaders
Self-conscious
experimenters
How does this
help me?
Minimize
uncertainty of
outcomes
Suspicious of
innovation and
change agents

30. Attributes of Innovations
• How is this better than what I currently
do?
• How is it relevant to the way I go about
my everyday life?
• Is it simple enough for me to do?
• Can I try it first?
• Can I watch others and see what
happens to them when they do it?

31. The Innovation Chasm
Source: Moore, G.A. Crossing The Chasm. Capstone Publishing, 1998.

32. Creating Webs for Change

33. Social Networks Frame the Opportunities
and Constraints for Change

34. Social
Networks
Opinion
leaders
Groups
Adding or
removing
members
Bridging
groups
Rewiring
groups
Network
weaving

35. Social Networks and Obesity

36. Adolescent Obesity and
Social Networks
• Intervene with the family
system, rather than with
the individual.
• Tailor family-based
interventions to the
structure of the family.
• Design support
mechanisms for parents
and adult family
members on the basis of
their social ties within the
community.
• Use peer networks to
encourage increased
physical activity.
Source: Koehly LM, Loscalzo A. (2009). Adolescent obesity and social networks. Preventing Chronic Disease; 6(3):A99

37. New Technologies Expand The
Scope and Capacity for Learning

38. Social Marketing

39. Designing products, services and
behaviors that fit people’s reality
Eating Well on $4.30 a Day
Our columnist lives for six weeks as if he is on
the Supplemental Nutrition Assistance
Program, and learns something he didn't
expect.
Brett Arends, The Wall Street Journal 14
December 2013
Eating reasonably well on $4.30 a day turned out to be a bit
like a Rubik's Cube puzzle: It seemed impossible until I
worked out the trick. Then it became surprisingly
manageable, if monotonous.

40. Positioning Behavior Change
What relevant behavior can
we ask people to engage in
rather than the one they are
currently doing?
How can we make this
behavior more compelling,
relevant, and potentially
more valuable to people
when they practice it, in
comparison to the
alternatives?

41. Brett’s Tricks
• I didn't eat out.
• I didn't eat any packaged or
processed foods.
• I didn't try to live on energy
bars.
• I avoided cheap carbohydrates,
like white bread and noodles.
• I abandoned buying coffee out.
For my caffeine needs I carried
tea bags instead

42. Costs of Change
• Financial
• Energy
• Geographical distance
• Opportunity
• Social
• Psychological
• Physical
• Structural

43. Brett’s Costs
• Peanuts and peanut butter
(which cost around $2.50 a
pound).
• Eggs (20 cents each).
• Pulses or legumes, like split
peas and lentils, which can
cost not much more than $1 a
pound.
• I rarely ate meats or fish. They
were too expensive.
• Milk is expensive, but I had a
cup—about 25 cents—a day.
• Healthy carbohydrates:
oatmeal, whole-wheat pasta,
brown rice, baked potatoes and
sweet potatoes, and whole-
wheat bread - which I made at
home and cost a little more
than $1 for a 1½-pound loaf.
• I ate plenty of bananas
(sometimes just 20 cents
each), and I bought frozen
peas, corn and other mixed
vegetables for around $1.30 a
pound.
• I took a cheap multivitamin a
day.

44. Creating equitable opportunities
and access
Where can we locate a service,
distribute a product, or create
opportunities for members of
our priority group to engage in
healthier behaviors?

45. Where Did Brett Go?
• I took the subway to
the bigger
supermarkets.
• And I hunted
aggressively for
deals.
• What's on sale is
what's on the menu. I
found the food aisles
at downtown
drugstores
sometimes had
surprisingly good
deals.

46. Communicating change in linguistically,
culturally relevant and ubiquitous ways

47. How Effective are Health
Communication Campaigns?
5%
5%
5%
5%

48. Brett’s Message
My experience has changed how I eat. I am amazed at how cheaply one can
eat well—and mortified at how much I have spent needlessly over the years. I
suspect I am not alone.

49. Keys to increasing healthy
eating using social marketing
Social marketing
benchmark criteria
Keys to increasing healthy eating using social marketing
Behavioral objective Evaluate healthy eating using multiple behaviors
Tackle single behaviors serially over time
Audience segmentation Identify different groups
Serve each group with a unique solution
Formative research Conduct formative research
Research must be consumer oriented
Exchange Offer salient benefits – short-term benefits can be more salient than long-
term benefits
Consider trials, rewards and prizes to stimulate trial and repeated behavior
Marketing mix Move beyond communication – interventions must be multifaceted (e.g.
more than promotion and communication)
Efforts need to be directed at initiating new behavior and encouraging
repeat behavior
Competition Undertake competitive analysis
Know your direct and indirect competition
Source: Carins JE, Rundle-Thiele SR. (2013). Eating for the better: A social marketing review (2000-2012). Public Health Nutrition; 28:1-12.

50. Lessons
• Theories should be tools – not straight jackets
• Theories can inform – and blind (the “frame
problem”)
• The one with the biggest toolbox wins
• It’s a complex world (the micro-macro gap).
• “There’s nothing so practical as a good theory”

51. Resources
• Lefebvre, R.C. & Bornkessel, A. (2013).
Digital social networks and health. Circulation;
127:1829-1836.
• Mullainathan, S. & Shafir, E. (2013). Scarcity:
Why having too little means so much. New
York: Times Books.
• Snyder, L. (2007). Health communication
campaigns and their impact on behavior.
Journal of Nutrition Education and Behavior;
39(Suppl.):S32–S40.
• Valente, T.W. (2013). Network interventions.
Science;337:49–53.
• Wakefield, M. A., Loken, B., & Hornik, R.
(2010). Use of mass media campaigns to
change health behaviour. Lancet; 376:1261–
1271.