I was recently part of a panel discussion at UXPA Boston Annual Conference on Designing for Behavior Change. This proved to be a topic of interest as the room was packed, and there were a number of questions at the end. Most people wanted to know how they could use behavior change models to help them find solutions to particular problems they were working on. One of the more interesting questions was about how to apply behavior change techniques to improve HEDIS scores, which I felt deserved a longer and more in-depth response.
HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures compiled by the National Committee for Quality Assurance (NCQA). There are more than 80 measures that are related to many significant public health issues such as cancer, heart disease, smoking, asthma, and diabetes. Because so many plans collect standardized HEDIS data, it is possible to accurately compare performance across different organizations. As the most widely used standard for comparing health plans, HEDIS is a high priority for most health insurance companies. With clearly defined objectives and measurable criteria, as well as addressing important healthcare issues, HEDIS measures can serve as the focused goals that direct behavior change programs.
At the conference we discussed a variety of models for behavior change. They ranged from the historical to the recent, from the complex to the simple. Because of its simplicity, Fisher’s IMB model is a great model to start with. It was specifically created to improve health-related behaviors, particularly medication adherence. If used well, it can produce useful insights and results. Because it is easy for people to grasp it can be used frequently and applied to a variety of problems.
According to J. D. Fisher’s IMB model there are three primary constructs that influence behavior change: Information, Motivation, and Behavior Skills. Information includes knowledge and ideas about the behavior, it may be correct or incorrect, and may facilitate or impede the desired behavior. Motivation is both personal and social, and includes any drivers of behavior including perceived benefits, potential side effects, and desire to comply with others. Behavior skills include a person’s objective ability to perform the task, as well as subjective factors, like confidence.
There are many ways that one could use the IMB model to inform a program of behavior change. Probably the easiest way to get started would be to begin with the information construct. There are many problems that can be solved by information alone. Providing information is often the first thing we do when trying to change behavior.
There are roughly thirty immunizations and screenings included in the latest HEDIS measures. Almost all of these are simple and can be accomplished in a short outpatient visit. Most of them are not controversial and people rarely object to them. One possible information strategy might include instructional pamphlets informing plan members about the screenings, how and when to get them, and any details around cost or coverage. In addition, members could be notified when it is time for these screenings through a secure messaging system. These simple and low cost information strategies will quite often result in the desired behavior. But what happens with this doesn’t work?
When you look at the results of your information-oriented screening campaign you may find that providing information and reminders worked well for breast cancer screening and flu vaccinations, but had little effect on childhood immunization status. If this measure is important to your organization it might be time to investigate motivation. The motivation construct requires a bit more time and money than information construct. It will require some research—usually surveys or interviews with the target population—and some analysis to figure out their motivations and the best approaches to facilitate behavior change.
If you look into the motivations that drive people to avoid vaccinating their children you may find a variety of reasons, as these researchers did. They found four primary motivations: Calculation, Complacency, Convenience, and Confidence. Each of these four motivations suggested different ways in which they might best be approached.
Some of the most engaged parents are motivated by Calculation. They do not have a strong pre-existing bias and will spend a great deal of time researching the benefits and risks of vaccination. They attempt to avoid the risks, by not vaccinating their own children, while relying on the benefit of low infection rates resulting from general overall vaccination. Appeals to social motives as well as information about the actual risks and benefits can best target this group.
Complacency happens when a person does not feel threatened by the risk of vaccine-preventable diseases and so their motivation for action is low. Adjusting the information intervention to specifically address risk perception and myth debunking, combined with mandatory requirements, or opt-in defaults could increase the vaccination rate with this group.
Convenience is a problem for those without access to care, usually resulting from the lack of nearby facilities or ability to pay for services. This group will be harder to reach and will require a combination of structural and support interventions. Incentives will be particularly useful for influencing this group.
Confidence is lacking in those who don’t trust the effectiveness or safety of the vaccines, the system and professionals that provide them, and/or the policy makers that recommend them. These people have frequently been exposed to a great deal of misinformation and they are the hardest to reach. Most efforts will be viewed as coercion and only serve to increase their reluctance.
The combination of information and motivation, when used creatively, will take you a long way toward improving most HEDIS issues. However, there are complex and difficult problems that cannot be resolved through information and motivation alone. The IMB model provides us with an additional tool, Behavior skills, to use to effect behavior change.
The HEDIS score for high blood pressure measures “the percentage of adults 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year.” There are a lot of factors that can influence blood pressure. Some people will have rapid success with simple interventions. Others will have to experiment with combinations of diet, exercise, medication and other lifestyle adjustments to achieve only modest results. Many of these interventions will require changing lifelong habits. Controlling high blood pressure could require a series of IMB steps: Information to provide an understanding of risks and potential treatments, Motivation to provide the impetus to change, and Behavior skills training to build the competency and proficiency for healthy actions.
These are just a couple of examples of how you can use a behavior change model to stimulate creative approaches improving HEDIS scores. HEDIS scores are useful because they provide a clear focus and foundation for a behavior change campaign. The IMB model is simple and easy to use, but as mentioned above, there are many other models, or combination of models, that could be used as well. It is best to start with a model you are familiar with. If you find it doesn’t inspire new directions and creative solutions, switch to another model that gives you better results. The possibilities are nearly endless.