Good afternoon, everyone, and welcome to the American College of Preventive Medicine's webinar on health behavior change. I'm Dr. Angela Michelide, the Vice President for Programs and Education at ACPM, and I'm very pleased today that we're being joined by Gail O'Sullivan to speak to this important issue. I will be introducing her shortly. The American College of Preventive Medicine is a professional medical society of approximately 2,000 physicians dedicated to improving health and the quality of life for individuals, families, communities, and populations through disease prevention and health promotion. Our members are licensed medical doctors who possess a master in public health degree and expertise in a broad range of health care skills, including biostatistics, epidemiology, management of health care organizations, research, and the practice of prevention in clinical settings. They work in a variety of work sectors, including hospitals, government at the local, state, and national levels, the military, laboratories, businesses, and academia. I have just a few housekeeping items as we begin. You have all been placed in a listen-only mode, but we ask you to please type your questions in the box throughout the presentation, and we'll respond to them at the end. We will be recording this webinar today, and it will be posted in our learning management system, so if you'd like to watch it again or share it with friends, please look for that in our LMS in a couple of days. Of course, we want to know what you thought, so we'll have a brief survey at the end of the webinar. So it gives me great pleasure today to introduce our speaker, Gail O'Sullivan, MBA, who is a thought leader in the social marketing and behavioral change fields. She teaches social marketing for global good as an adjunct professor in the Madonna School of Business at Georgetown University. Ms. O'Sullivan's expertise includes more than 30 years of global health experience designing, implementing, and evaluating programs that prevent illness and unintended pregnancy, empower women and girls, help sick people get their curative services when they need them, and strengthen the media and policy advocacy environments around those issues. Ms. O'Sullivan has worked in the U.S. and more than 40 other countries across topics such as family planning and reproductive health, gender equality, infectious diseases such as HIV, AIDS, malaria, and avian influenza, alcohol harm reduction, and tobacco control and prevention. So without further ado, let me introduce our speaker and turn the podium over to her. Thanks very much, Angela. It's nice to be with you all today. I think Stephanie will be advancing my slides for me, so next slide, please. If you skip the agenda, there we go. So these are the topics that we're going to try and cover in our few short minutes together today. I'm going to review a few of our key foundational concepts in behavioral science, talk a little bit about behavioral counseling, especially since I think we have some clinicians in the crowd, talk about COVID-19 and behavior change since it is the hottest public health topic of the day, but I will touch on a couple of other examples as well and end with some messaging tips and resources. Next slide. So let's start with some concepts around the term behavioral science. Next slide. So I always like to start with this slide because it's so true. Behavior change is really hard in general, and particularly when it comes to health behaviors. Many people would rather adopt a really quick solution like taking a pill or even having surgery as opposed to working every day to change their habits or lifestyles to improve their health outcomes over time. Next slide. We've seen in the popular literature in the last 10 years or so just an explosion of books, which is great because it shows that a lot of the concepts that we work with in health behavior change and behavioral science are really getting mainstreamed across our culture. So we lean into a lot of different disciplines here, including behavioral economics, psychology, anthropology, social marketing, human-centered design. All of these disciplines have something to offer us to help us understand better what drives human behavior and how to change behavior. And you can apply these concepts to not just public health, but any other sector like climate change or girls' education. And you can apply these concepts in your personal life as well as your professional life. I do want to note when I say behavioral science and behavioral health, I realize that it might be a little confusing because those of you who work in clinician settings tend to use that term behavioral health around addiction issues and tobacco, alcohol, and mental health issues. So I just want to be clear that when I say behavioral science, I'm talking about sort of this multidisciplinary approach using behavioral economics, psychology, social marketing, et cetera. And I also want to just say that for some reason, the public health field has really been the thought leaders in this space for over 30 years. A lot of the ideas and the strategies that are being used now to tackle other issues like climate change are really grounded in the evidence that we've been generating in public health for the last several decades. Next. So let's dig into what drives our behavior. We'll unpack this first at the individual level. Human beings are really messy when it comes to processing information, assessing risk, and making behavioral health decisions. We tend to use mental models or heuristics to sort through vast amounts of data very quickly and many of our behavioral health decisions are made unconsciously. A lot of public health messages focus on information and transmitting knowledge. And while knowledge is one of the determinants of behavior, it has to be combined with a lot of other variables to motivate someone to actually behave in a new or different way. So our brains are constantly toggling between tensions along several dimensions, as you can see here. The first one is me versus we, or our tendency to want to behave in a way that improves our own lives versus our more altruistic motivations that might lead us to want to behave in a way that benefits others in our community or society overall. The next one is fear versus control. There's probably no stronger human instinct than self-preservation. And in a situation like this pandemic, fear is fueled by the many unknowns of a virus that is lethal, behaves in quirky and unexpected ways, and can be spread by people with no symptoms. COVID-19 is a terrifying disease and it's hard to feel like you're in control with so many unknowns, even if you follow all of the recommended precautions. The next one is cost versus benefit. One of the mental models running through our brains constantly as we process what's going on around us is the calculation about what that cost of the behavior change represents to us versus the perceived benefits of that change. This can also be described as a risk-reward or incentive-disincentive calculation. Behavioral science tells us that a number of behavioral determinants have to act together to actually impact whether we make a behavior change, as I just mentioned earlier. So in addition to knowledge, we have to look at facts like how we change factors, such as how we change attitudes, personal values, and self-efficacy, if we're going to help people change successfully. And let me just say a word on self-efficacy in case that's a term that you're not familiar with. It has to do with a person's feeling of confidence that they can actually carry out the desired behavior change. Once they're aware of the change and the benefits it might bring, they might have a positive attitude about it. They might have all the knowledge and the facts and know where to go to get the product or service or whatever the change is you're trying to instill. But at the end of the day, if the person doesn't feel confident that they can actually follow through, that's where a lot of behavior change efforts tend to fall apart. And then lastly, we're not operating in a neutral environment. Often with health behaviors, as we're seeing right now with the anti-mask and the anti-vaccine efforts, there are countervailing forces that make clear communication, persuasion, and effective behavior change even more difficult to achieve. In our current environment with social media immediately blasting messages and literally going viral around the world, it's extremely challenging to deal with rumors, misinformation, disinformation, and generally what Dr. Peter Hotez calls anti-science aggression. Next slide. So there are many useful behavior change theories, models, and frameworks that inform our work, but here are a few that I find particularly relevant, especially during the time of the COVID-19 pandemic. The first is called the extended parallel process model. It's often used in pandemics because this model breaks down how behavior change happens in this type of an emergency situation. There are two sets of factors that have to work together to cause behavior change. On the one hand, an individual has to perceive a threat as severe and they also have to feel that they are very much at risk personally. And then on the other hand, the individual has to believe that there are effective response measures available and that they themselves can do something to reduce their risks. So those two sets of factors have to work together to be able to drive behavior change in an emergency type of situation. A lot of this comes down to really helping people accurately assess risk. The second model I wanted to mention briefly is called the socio-ecological framework. It helps you understand all of the different spheres of influence that can impact an individual's health behavior and it can inform a multi-channel strategy to ensure a holistic approach. We are all social creatures, so we can't just assume that if we give people information and access that change is magically going to happen. A lot of our health behavior change decisions are made as a function of what we think our spouse or our friends or our family members might think of us if we do this thing. So we need to look at all these different spheres and how they interact together. And then there are just a whole number of social science principles that are from the broader literature and are really informing our work as well. So given our time, I'll just mention a couple of them here. So there's implicit bias, which is really around sort of helping people understand that, for example, Asian Americans, especially early in the pandemic, were feeling sort of attacked and judged just because of the virus and the whole narrative around it coming from China. A lot of people were implicitly biased against that population just because of the origin of the virus. That's implicit bias. Another concept is the Dunning-Kruger effect, which I like to describe as the reason why your cousin Kenny is an instant expert on the pandemic. This refers to the fact that people often overestimate their level of knowledge and expertise on a particular topic, especially in a situation with a lot of unknowns. Anchoring is a really useful concept to know about. This really explains how you can manipulate expectations about what is normal when you pick an arbitrary endpoint and then debate or negotiate from there. We saw that early on in the pandemic when the government was predicting 200,000 people total would die from the pandemic, and they were hoping that only maybe 100,000 would die, and then they would look like they did a better job at the pandemic. Next slide. So again, we are social creatures, and so we need to understand the role that social norms play in individual health behavior. We are really looking for our peer approval and our social benefits when we're making a lot of these decisions. A couple of terms that are helpful here are descriptive norms and injunctive norms. Descriptive norms really relate to what you observe happening in your daily life, like people wear helmets on motorcycles out when you see them in the street, or in the time of COVID-19, people are wearing masks when they're in public. Injunctive norms are more about value judgments. It's about what you think is socially acceptable or unacceptable, and again, we've seen huge debate in this country about masks and whether that behavior should be the norm or whether there's value judgments that are implicit in the wearing of a mask or the not wearing of a mask. Tipping points are sort of helpful because if you think about it with masks, when we all started wearing them, I think, you know, for those of you who are doctors and clinicians, you're much more used to wearing masks, but most of the general public is not. I know I felt really sort of foolish and self-conscious for probably a good month or so when I started wearing my mask out in public, and now nobody even thinks twice about it when they see somebody wearing a mask out on the street, right? We've created a whole new social norm around mask wearing that didn't exist a couple of years ago, so that we got to this tipping point where all of a sudden, you know, most people were doing this. Next slide. So social marketing is another useful discipline in my passion and in my career. I teach this at Georgetown, as Angela said, and I'm just going to, you know, give you kind of a 30-second description of what this means. So social marketing is taking all the principles that are used in commercial marketing but applying them to a social goal. And some of the key concepts here are really, really understanding your audience in a very genuine way. So we always start with deep-dive audience research, and you have to do segmentation because, of course, all audiences are not the same, and so the more you can tailor messages, the more successful your efforts are going to be in terms of promoting a health behavior change. We use this four Ps framework, which I'll go into a little more detail about next. Product place price promotion. A lot of us also add a fifth P called policy because we've seen over the years that policy can really help drive health behavior change, and so it's helpful to build that right into the design of any program that you're doing. And as we know, there's a lot of barriers to getting people to change, and so one of the key concepts in the whole field of marketing, whether it's commercial or social, is this notion of exchange theory. So I'm asking you to pay money for a product or a service, and in return, you perceive you're getting some kind of a benefit from that. And it's the same in social marketing efforts, whether a product or purchase is involved or not, you're asking somebody to do something, they have to see a benefit from whatever it is you want them to do. And one of the golden rules of social marketing is that we always want to make the change as fun, easy, and popular as possible. A lot of us in the health field, and I should specify, I do have an MBA, I have absolutely no formal training in public health, but I've worked in global health for over 30 years, so my experience is all field-based. But we've seen time and again that a lot of efforts in the public health community tend to be sort of clinical in nature, in the sense that we want to educate people and just give them all kinds of facts and statistics and knowledge, and while all of that is well-meaning and good, it's not going to get you where you need to go to actually promote behavior change, especially over the long term. So the more we can steal from commercial marketing where, you know, some of your favorite ads are probably the ones that make you laugh, they're entertaining, why not use the same approaches to health behavior change? Let's make it easy and fun, and popular just refers to, again, the normative piece of let's sort of set the tone that everyone's doing this so that people feel socially supported when they make the behavior change. Next slide. So this is just a quick word on the four Ps of marketing. So the product, service, or behavior, again, it doesn't have to involve money, is what do you want people to do or buy? What's the difference that you're trying to get them to make? And then the place refers to where can they access the product or service, or where do you want them to perform the behavior? Price is not just, again, a monetary construct, but price can be, you know, opportunity cost. Like if I go to a clinic to get my vaccine shot, but I have to wait for two hours in the waiting room, that's a huge cost to me. So you have to think about, you know, sort of barriers or what behavioral economists call sludge in the system, which are disincentives for people. You want to make the change, again, as easy for people to follow through on as possible. Promotion is the one that everyone loves to talk about, because those are the fun, you know, ads and TV spots and things that you see. So it's how are you going to reach and engage with your audience? And how are you going to promote the product? What's the key message? What's the benefit to the consumer? Why should they do what you're saying over what everybody else is telling them to do? And then again, policy can really facilitate scaling up and sort of institutionalizing behaviors. One of the very earliest examples of that here in the U.S. was, you know, the seatbelt laws that started to come into effect about 50 years ago. If you can mandate it, then people, you know, are going to get on board with that behavior a lot easier. We're not having such an easy time with the vaccine mandate debate right now, but in general, policy can really drive behavior change at scale. Next slide. So just a little bit about sort of what some of you do in terms of how this all relates to people who are talking to patients in a clinical setting. Next slide. So I wanted to sort of ground this in sort of what do we know from the evidence about how to drive behavior change? And I went and looked at the U.S. Preventive Services Task Force listing for behavioral interventions that get an A rating in terms of the evidence. And there's only two that I saw. One is the evidence behind smoking cessation in adults and pregnant women in particular. And then the other one was around folic acid for pregnant women. So I think I was a little surprised that there weren't more. I don't know if the evidence is out there and just not being captured or if we need to have a more concerted effort to generate and document the evidence for what we can do with behavioral interventions with encouraging patients. But yeah, I was surprised that I only found two with an A rating. Next slide. So another interesting article I saw thinking about these issues is that I'm sure most of you who counsel patients know about this five A's framework, right? Ask, advise, assess, assist, arrange. What this study is showing is that most physicians are routinely asking and advising their patients. This is obviously about weight loss. But they rarely are assessing, assisting, or arranging. So this study is calling for physicians to try and more consistently, again, go along that behavior change continuum of not just sort of starting the conversation and giving advice, but then equipping the patient with some tools and concrete next steps to support them once they leave the office visit to actually execute the behavior that you're trying to get them to perform. Next slide. Another new study that I just saw is interesting. It's about how physicians are not communicating as clearly and effectively with their patients as they might. And so what this study found is that most doctors are using language that's too complex for their patients to understand. But some have the ability to tailor their language to meet their patients' communication needs and overcome confusion. So this is called precision communication, where you can tailor the word choice and the messaging to the needs of the patient. And no surprise, but this is especially helpful, they found, for the one in three Americans who have low health literacy. So something to keep in mind for those of you who are in patient-facing roles. Next slide. So I know we can sort of laugh at this, but it's kind of sad but true that even doctors were used to promote smoking way back in the day. And of course, there's still a fair number of doctors who smoke today. And so when I show this slide to my students, it's just to underscore that point that knowledge is not the problem here. Doctors know that smoking is not good for your health, but yet they still smoke. Why? Right? So there's other drivers of behavior that you need to really research and unpack to understand how best to move somebody along a change pathway. Next slide. Okay, so I know everyone's sick of COVID-19, but it really is the best case study to dive into to kind of illustrate what we're talking about. So next slide. And this is just to sort of ground us by saying everyone is burned out and healthcare workers are at the top of the list. This article sort of made me chuckle, but also makes me sad because I don't know if any of you are familiar with the Greater Good group out of UC Berkeley, but they have like a whole happiness lab that's very science-based and they put out great tools. And so this guy is a happiness journalist and he's talking about how Omicron is crushing him. Like even as somebody who specializes in how to find joy every day, he's really struggling. We're all struggling. Next slide. Yeah, so again, we're trying to get individuals to change, but we're also trying to drive social norm change at the same time. And mask wearing is kind of the first obvious example that we started working on about two years ago. So we're asking people to do a lot of things differently, not just wearing masks, right? And there's been a lot of mixed messages out there. It's acknowledged that the messaging in general around COVID in our country has been less than stellar. There's a lot of lessons to be learned here, which I'm sure are going to be taught for many years to come in public health and other programs. But we're asking people to sort of deal with this big unknown and to change a lot of daily behaviors all at the same time. And it's overwhelming for people. Next slide. So think about handshaking. Handshaking has been around for hundreds and hundreds of years, right? And now all of a sudden, we're not supposed to shake people's hands. Some people are doing the elbow bump. Some people are crossing their hands over their chest and bowing and greeting. But that's like a whole new way to greet somebody now. That is a huge cultural change from what we're used to. Next slide. And then this distancing piece. Just a pet peeve of mine, I don't like to see that term social distancing because we really need to be supporting each other socially as much as we can. can during this really difficult time. I would much prefer that people say physical distancing, because we're really talking about physical separation, not a social separation here. And there's lots of different ways that that's playing out. But you know, one of the best ways, again, to make it easy for people, just put stickers on the floor that are six feet apart with those little footprint images. And you know, your brain automatically says, oh, I need to stand there. You know, and here they've underscored it with please stay two carts apart. So now you have a mental model of, oh, how much length are two carts, and then you can use that as a marker for where to stand. Next slide. I love this example, because it's from the Midwest, from a rural farming area. And they're, you know, using the size of a cow is a relevant measure to try and explain to people how far apart they should be standing. So again, it's about knowing your audience and really tailoring your messages to, you know, their daily lives and making it relevant for them. Next slide. And then another daily behavior, of course, that we're trying to promote always in public health, but especially during a pandemic and flu season is washing your hands. So that's a tough one, because a lot of people don't wash their hands, they don't see the benefit, you don't see the germs. This is a good graphic because it shows, you know, that your hand actually is covered in germs if you don't wash. But a lot of people washing correctly, there's a lot of behavior change research around like hand washing, how to do it correctly, how to get people to do it multiple times a day. But you pair that with the physical distancing, with, you know, not hand shaking, but doing something else with wearing a mask. It's a lot of daily behaviors to think about. Next slide. And then on top of all that, now we want people to go get vaccinated, right? This is, I know you can't read this infographic, but it's from the World Health Organization. And it's sort of a brainstorm session from their behavioral science team about how they could imagine, you know, developing campaigns to promote vaccination and sort of what leaning into the science and the evidence, what some of the considerations and variables are. And getting a vaccine is very different than the other daily behaviors, of course, that we just reviewed because this is a one-time, two-time, now three-time behavior for most of us. And there's this active sort of anti-science aggression happening in the media. So people are really confused. Who do you trust, you know, about whether it's safe and whether there should be mandates? Next slide. All right, now Stephanie is going to see if this video will play. Let's try it. Whatever I do, I always want to do my best for the teenagers. I certainly never want to do anything that would be a wrong influence. In the fifties, the polio epidemic overtook America and the world. Like the COVID-19 pandemic we face today, scientists hoped a vaccine would extinguish the dreaded disease. The problem was the majority of teenagers who are at a high risk of contracting polio weren't interested in getting vaccinated. Today, public health officials face a similar challenge. In the fifties, they turned to Elvis. Elvis's career had skyrocketed after a memorable appearance on the Ed Sullivan Show. Now, ladies and gentlemen, yes, that's right, Elvis Presley. ♪ You ain't nothin' but a hound dog ♪ This is Elvis Presley. I ask you to listen. Remember me. Now that's the voice of thousands who know the fight against polio is just as tough as it ever was. Some of them are paralyzed so that they can't even move a finger. Others can't do the simplest everyday things that we take so much for granted. Elvis publicized his inoculation backstage at the Ed Sullivan Show in 1956. Teens across the country followed in Elvis's footsteps and got their shots. Today, three former US presidents are talking about getting their COVID-19 vaccinations on camera, encouraging people to get their shots. So President Bush, President Clinton, President Obama, put your antibodies where your mouth is, come on my show and drop trow backstage at the Ed Sullivan Theater in my late show, Immunotabulous Ex-Presidential Jabberama featuring physician's assistant, Snoop Dogg. You are going to get the vac-sizzle. So, you know, it's such a great example because we were able back in the 1950s to do this the right way, right? The main group that were not getting the polio vaccine were teenagers and who better than Elvis Presley, who was the biggest, you know, rockstar of all time to put that message out there, model the behavior, go around talking to those kids. I mean, it worked, you know, he did a great job in boosting vaccination rates among that population. Next slide. Whatever I do. So going back to sort of the broader media and communication environment, the WHO has actually termed this sort of disinformation, misinformation, whatever you want to call it, an infodemic because there are so many conflicting messages out there. And there's a whole team of people working at WHO right now on strategies for combating that. So all of this to say, you know, it's not a simple communication environment like we had when Elvis was doing this. And there were only three television stations in the whole country. And, you know, it was a much simpler environment we were working in. Next slide. This is a recent ad from the ad council. So let me see if this one will play. COVID-19 has changed how we express our faith and gather to worship. We all want to get back to how we pray, how we congregate, how we lift our voices in praise. Now it's time to take the first step that lets us get back to spreading the word without spreading concern. Yeah, yeah, yeah, yeah. Before we can safely come together, we need the facts. As COVID-19 vaccine become available, you may have questions. Should I get it? Is it safe? Should I wait? It's okay to have questions. Now get the facts. Learn more at getvaccineanswers.org so you can make an informed decision when vaccines are available to you. Now I have some mixed feelings about that ad, but I think one of the reasons I wanted to show it is that it does emphasize the getting back to the social norms that we're all missing as the benefit for the vaccine. It doesn't really talk about how you're gonna avoid illness and death. It's like, you know, if you do this, we can get back to things we love, like our church community or other community and social structures that we're all not able to enjoy right now. So again, thinking about health messaging with lifestyle benefits or, you know, not necessarily the straight clinical health benefits is a good strategy in general. Next slide. And this, you know, I have to update this because the list is even longer of legitimate questions. But, you know, back in the beginning, the whole effort was called Operation Warp Speed, which to be honest is really not an effective name or a good name for something that, where you're trying to convince people that it's safe. It sounds like you're rushing and going too fast and maybe skipping over some key safety steps. You know, there's been the, again, a lot of misinformation about fetal tissues. Pregnant women initially were not included in clinical trials. Now we have good data about safety in pregnancy, but in the beginning we didn't. So that was a legitimate question. And unfortunately, a lot of the communication in the early days was from the pharma companies themselves. And they were, you know, communicating via press release and framing the debate and the issues instead of, you know, public health people framing the discussion. And then there's the whole debate about which type of vaccine are some safer than others, how many doses, et cetera. And then once you are vaccinated, does that change what you can and can't do around, you know, wearing masks and things like this. So it's just really unfortunate that there's been a lot of confusion and mixed messages. Of course, science changes. So messaging has to change with the science as we learn more. But I would offer to you that we could have done a much better job in general with how we've communicated around all of this. Next slide. I wanna give a little shout out to ACPM because I saw we are vaccine confident. I was really happy that that was in your message. We're trying to sort of move away from negative words like hesitancy and really always try and frame the discussion around we're using positive language and with a positive benefit. So good job on that. Next slide. I'm just gonna give two quick other examples beyond COVID because I know we don't wanna always just focus on COVID and then we'll wrap up and hopefully have time for questions. So next slide. So let me set this up before you hit play, Stephanie. So some of you may be familiar with the Truth Initiative, which does a lot of youth campaigns around smoking. And of course, in the last five or six years, vaping has become a huge issue with that population. And what they have found through research is that a lot of young people turn to vaping and smoking thinking that it's gonna help sort of quell anxiety and calm them down. And it turns out that the science is showing that it actually increases anxiety and depression symptoms. So knowing all of that, and again, knowing how the vape industry is going after kids and sort of manipulating the science, they have just a couple of months ago launched this new campaign and this is the depression stick spot. Okay. If you like anxiety, you'll love depression. Vaping nicotine can amplify feelings of depression and anxiety. Depression stick, learn more at depressionstick.com. So there's a whole series of ads that you can look out for this campaign. The campaign is actually called It's Messing With Our Heads. That's the kind of bigger umbrella. And then this depression stick is one of their main focus areas. And you can see obviously that their spots are very much geared to like the TikTok generation with bright colors and short videos. And this is how the only way to apparently reach teenagers these days, they're all on TikTok. But what I love about the Truth Initiative is they really do lean into all the science. They do tons of audience research. They pre-test and pre-test to figure out what's really gonna work with the audience that they're trying to reach. And they've had a really good track record, especially with these campaigns directed to very young people. Okay, one more example. Next slide. So Peloton has taken over. Yeah, I think because this is about an eight minute video, Stephanie, we won't play it. I'll just kind of summarize. I know just in the last few days, Peloton has been in the news and not for good reasons. Their stock prices plummeted. And I heard last night that a second TV show just depicted a character having a heart attack on a Peloton bike. So as a company, they're dealing with some big challenges right now, but up until recently, they've done an amazing job with promoting their product and getting people to exercise regularly on these bikes. And again, in the time of COVID, where a lot of people are not comfortable going to gyms and people are stuck at home. But what this would show you, if you wanna watch it afterwards, is how they lean into behavioral science to get people to buy these $2,000 bikes and then pay the monthly subscription fee. That's called sunk cost fallacy, by the way. And then there's a whole bunch of other behavioral science ideas that they've leaned into, habit formation science as well, to become the premier brand in this market. Just conscious of time. So let's go to the next slide. Or the fitness. Next slide. So just some really high level kind of summaries of what to do, what not to do. This is what not to do. We don't wanna be repeating rumors and misinformation. That is an issue I had with the African-American church ad that we saw. It is true that it's okay to have questions, but they put up some of the questions that sort of reinforce some of the negative aspects of COVID that we're trying to sort of address. And so just by repeating rumors or repeating questions that sort of plant seeds of doubt in people, that's not a great way to change behavior. Reinforcing hesitancy, talking about vaccine confidence instead of hesitancy, which I mentioned. You don't wanna be using all that clinical terminology, even though that might be your training and the study I shared supports that. Blaming and shaming, of course, are never strategies we want to use. That is not going to be a long-term strategy that's gonna get you where you wanna go with your patients. And we don't wanna overemphasize the medical and technical at the expense of social and cultural, right? We need to think about a day in the life of the patient and what's gonna happen when they leave your office and they go home, what's their setting like? Who influences them? Who do they trust? And really lean into all of that to frame the behavior and the way that's gonna work for them. Next slide. So what to do? Again, the five A's is a handy framework and we wanna lean into acknowledging concerns, active listening, asking questions, using that game frame and not a loss frame. It's okay to say, I don't know. You can identify other trusted sources of information, give people other places they can go, people they can talk to to help inform them and help them sort of get where they need to go in their behavior change process. We love to emphasize stories over statistics. Again, we are social creatures and people will remember a story a lot more than they will remember numbers. And then just remember that behavior change is a process and trying to get a two-time or three-time vaccine uptake behavior versus the daily mask wearing, et cetera, they're very different changes and they lean into different principles of behavioral science. So make sure you're tailoring your message for the kind of behavior that you're trying to promote. And then give people a concrete call to action. What do you want them to do when they leave your office? Are they gonna go to a website, call a hotline, agree on a follow-up time for another conversation? With vaccine appointments, there's great research from Philadelphia, from the Wharton School that showed when people got a text message reminder that said, Susie, your vaccine appointment is at 10 a.m. on Saturday. This time has been reserved especially for you, like really personalizing it. Even though it's a text message, they found in their research that by doing that, they boosted vaccination rates significantly. Next slide. So at the end here, you could go to the next slide. There's just a list of some resources for any of you who wanna go deeper on any of these topics. There's a bunch related to COVID because I've done a number of talks about COVID-19, obviously, but if you keep going, Stephanie, next one. Next one. Yeah, and then there's some webinars and webcasts or podcasts that I recommend for those of you who wanna really hear from some of the thought leaders across the behavioral science field. So I think that's it. Next slide. Yes. So all of this to say, yes, it's a very complicated space and we're very complicated beings, but if you lean into all of these evidence-based practices and do kind of the deep dive audience research and follow all our best practices, you'll get much farther than just trying to throw together quick messages and quick campaigns that are not tailored to what the behavioral challenges really are. So with that, I will turn back over to Angela. Thank you so much, Gail. Really appreciate this thought-provoking presentation. I have a few questions in the chat for your consideration. The first is with the advancement of technology and the rise of social media, how have behavioral trends shifted in balancing self-interest versus the social? Yeah, that's a great question. I don't know of any studies on that off the top of my head, but as somebody who's worked all over the world, I will tell you it's so striking to me how American culture is leaning into that individual liberty and freedom sort of framing around all these issues, which is not the case in most of the rest of the world that I work in. I mean, so many of the cultures I work in, people's first instinct is about community. It's about family. It's about trying to protect everyone. And I talked to people in Africa and other parts of the world. They're always commenting to me about what is it with you Americans? You just wave that flag and it's all me, me, me. And it's just a very different mindset. So there's definitely a unique culture here. And I'm sure the social media platforms are fueling a lot of that messaging, but I don't know of any research to answer that specifically. Thank you. I personally have long been interested in this idea of additive behaviors versus subtractive behaviors when we think about health promotion and disease prevention. More specifically, subtractive behaviors include stop smoking, don't drink, don't eat these foods. Whereas additive behaviors include wear your seatbelt and bike helmet, begin exercising at least X number of minutes per day at the beginning and eat fresh fruits and vegetables and lean protein. What is known about the relative effectiveness of physician counseling and healthcare counseling regarding these behaviors? Essentially, is it easier to get people to stop doing certain things or to start doing certain things? Yeah, again, I'm not a physician, so I don't know about in that setting specifically, but from all my years of experience, it's a lot harder to get people to stop what they are doing than to start a new behavior. Because your brain is literally, you're laying down these neural pathways, like you associate going to a bar with a cigarette or your mind is like, you don't even realize you're making these associations in your brain. And so before you know it, every day you come home from work, you open that bottle of wine. It's like an automatic behavior. So unpacking that and unlearning that is a much harder process than starting a new habit. Wendy Wood is one of the thought leaders in the habit space. She's written a bunch of great books if anyone wants to dig into habit formation. But in general, it takes about 30 days to really lay down the pathway for a new habit that's going to stick. And you start like 15 minute increments a day and you build up, especially with things like exercise. That's a lot easier. And when we know a lot better how to do that, I think then how to unlearn the other behaviors. You spoke earlier about the US Preventive Services Task Force, which I think most of our audience is aware of. It's an independent body that examines the scientific evidence and makes recommendations for clinical practice. You only found two level A recommendations within that set of recommendations that you looked at. What next needs to happen in order to get us to more A-level recommendations in your opinion? Yeah, this is one of my passion projects because in my opinion, a lot of it has to do with not capturing the evidence that's already out there. We have a real problem in our field and it's ironic because a lot of us consider ourselves to be communication experts, but we actually use really confusing and overlapping terminology. And so there's social marketing, there's health education, there's health communication, there's social and behavior change, there's communication for development. There's like so many overlapping frameworks and sets of lexicons out there that unless you know in a lit search to search for all those different versions of what we do, you're gonna miss a lot of the evidence that's already out there for what we know works or doesn't work. So I feel like these bodies that are trying to curate and document, like what does the research tell us? I don't know what their search criteria are, but I would posit that they're probably missing a lot of what we already know works because they're using narrow terminology definitions for this health behavior practice that they're looking at. Thank you for that. Here's another question from our listeners. What specific aspects of tobacco cessation make it a program? Not really sure I understand that question. Make it an A program, sort of. Are you aware of what components need? Oh, for the guidelines team? Oh, sorry, yeah. No, I did look into that. And it's basically they're looking at physician counseling, right? There's so many other things you could do to help somebody quit smoking, but they were looking at the window of when a patient and a doctor are together. And so they do have research that shows that when patients successfully counsel, when doctors successfully counsel their patients on the benefits of quitting smoking, that that actually did impact quit rates. So they do have documentation that that works. But again, that's one intervention that's happening in a bigger environment, right? So the person probably also had a spouse or somebody at home that was encouraging them and supporting them to stop smoking, right? And they may have seen media messages around the harms of smoking, lifestyle benefits for how you can run faster and breathe better once you stop smoking. So I think it is a little hard to say that it's like this one thing that works because we have many touch points throughout our day that are influencing our attitudes and our behaviors. So, but in the context of the task force, that's what they found is that in that one setting, they had a causal link between the counseling and the quitting. You know, Jerry Franz adds in the chat that when the U.S. Preventive Services Task Force gives an A grade to a preventive behavior, the committee saying that the behavior is directly tied to reducing morbidity and mortality. But we know that so many of these behaviors that we've been talking about today influence so many infectious and chronic diseases and even injuries and violence when we think about alcohol and other drugs. It's a very important area. And Gail, would you agree that we just need to increase the research budget so that we can begin to build the evidence? I think a lot of the behavioral science recommendations, several of them have an I, you know, incomplete. So we need to be investing in this. Absolutely. It's, you know, I think for whatever reason, behavioral programming, it's like the forgotten stepchild kind of analogy. Like it never gets put at the top of the list, even though it, in my humble opinion, probably has the greatest impact on health outcomes. We're much quicker to like, you know, create a new drug or have some technical intervention. But like just the daily behavioral stuff, for some reason it doesn't seem to get the research attention and the priority in public health that we'd all like to see. And it's also truly a team effort of many healthcare providers. Not only the physician, but the nurse practitioner and the physician's assistant and the health educator and the nurses all coming together with the information and the tools and the skills building to help the patient. Yeah. I do think we need to go beyond public health too, right? Like there are all these other related social science disciplines out there that have a lot to offer that can expand our toolkit and our approaches. So I really encourage that as well. Thank you very much. That's all the time we have for questions. I have a few concluding remarks, which is first and foremost to thank you so much, Gail, for sharing your time and talent with us. We will be able to provide you with those lists of resources. We can send an email with those slides to all of you on the call. I wanted to call your attention to a survey that would just take you 30 seconds to complete. We'd appreciate that. And the American College of Preventive Medicine has a learning management system just chock full of courses for your edification. But in particular, I wanted to be sure that you were aware that the newly revised Lifestyle Medicine Core Competencies course is set to be released at the end of this month. ACPM has been working in partnership with the American College of Lifestyle Medicine. And this, we're beginning our seventh year of partnership. You'll be able to purchase this course from ACPM by logging on to learn.acpm.org for both your professional development and the skills, particularly for those of you who have residence. The full course package will allow you the opportunity to earn 32 CMEs. And we're really excited to provide this valuable opportunity. So as soon as the course launches in a few days, we can send all of you on the webinar, a link to the course and feel free to reach out if you have any questions. In addition, I'm delighted to share that the ACPM Annual Conference PM 22 will be held June 15th through 18th in Denver. And we've extended the poster abstract submission deadline to February 18th, as well as our early bird registration. So please check out both of these opportunities on our website. And with that, I thank you and wish you a wonderful day.

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health behavior change

behavioral science

COVID-19 pandemic

social norms

social marketing

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communication