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Applying Health Promotion

Intervention Principles to

Climate Change

Carrie Armel, Ph.D.

Thanks to: Thomas Robinson, Linda Schuck, June Flora, Jeff Shrager, Katy Yan,

Lindsay Allen, and the students of Human Biology 169.

Applying Health Promotion Intervention Principles to Climate Change

Carrie Armel, Ph.D.

Thanks to: Thomas Robinson, Linda Schuck, June Flora, Jeff Shrager, Katy Yan, Lindsay Allen, and the students of

Human Biology 169.

Precourt Institute for Energy Efficiency

Stanford School of Medicine

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Complementary Interventions

Physical Environment - Built Environment - Technology

Policy

Sociocultural

Interpersonal

Individual

•Interactions between levels•Complementary interventions

For at least several decades the field of public health has put an exerted effort into changing behavior in order to

address problems like smoking and heart disease. The field has employed interventions at multiple levels. I’ll illustrate

some of these with examples related to climate change:

•At the individual level there is no intervention - people do research on their own and figure out how to make lifestyle

changes. That’s incredibly effortful and we can’t reasonably expect that the majority of people will do this.

•Interventions where there is interpersonal or face-to-face contact, often with an expert leader, include energy audits,

and programs at schools, faith-based organizations, Girl Scout troops, YMCAs, etc.

•The sociocultural level includes media communications – such as serial dramas and public service announcements,

through TV, newspaper, etc.

•There’s policy interventions like carbon taxes or carbon reduction goals in corporations.

•And there’s interventions at the level of the physical environment. These include characteristics of the built

environment, like whether a city is walkable, and of technology, like whether programmable thermostats are intuitive

so that people actually use them – right now 70% of people who own them say they’re too complicated to program!

There are lots of interactions between all of these levels – For example, new technologies can facilitate changes inindividual behavior, media coverage, and policies.

There is general consensus in the field of public health that complementary interventions at multiple levels areimportant for effectively producing change – that is, making a city walkable but not promoting walking clubs and mediacoverage will produce minimal effect.

I’m going to be focusing mostly on the interpersonal level in this talk.

As an aside, I’ve talked to several high-level public health people who are interested in addressing climate change asa public health issue, but very few people in public health have started transitioning yet.

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A Model for Validating &

Disseminating Interventions

Thomas N. Robinson, Professor,

Stanford Prevention Research Center

Develop, test, and disseminate validatedcurricula to schools and YMCAs toreduce obesity and TV viewing.

Guided by theory and empirical studies.

Robinson TN, Killen JD, Kraemer HC, Wilson DM, Matheson DM,Haskell WL, Pruitt LA, Powell TM, Owens AS, Thompson NS, Flint-Moore NM, Davis GJ, Emig KA, Brown RT, Rochon J, Green S, VaradyA. (2003). "Dance and reducing television viewing to prevent weightgain in African-American girls: the Stanford GEMS pilot study." Ethn

Dis, 13, Suppl 1, S65-77.

GEMS

Robinson TN & Borzekowski DLG. (2006).Effects of the SMART Classroom CurriculumtoReduce Child and Family Screen Time. Journal

of Communication, 56, 1–26.

Develop Test Disseminate

Revise

I’m currently working with a health promotion researcher, Professor Tom Robinson, on an intervention to promoteclimate-positive behavior. In the past, Dr. Robinson and his colleagues have developed interventions to reduceobesity and TV watching. For example, kids who went through his SMART program reduced their use of TV,video, and video games from about 3 hours a day to under 2. His GEMS and GAMES programs got girls tosignificantly reduce their weight.

These interventions are now used by schools and YMCAs throughout the country. Development of this curricula wasguided by a large body of theory and empirical studies, and the interventions were refined and evaluated severaltimes to improve their effectiveness before being disseminated.

I think this approach is particularly valuable for 2 reasons:

1. It ends up that interventions are oftentimes much less effective than we think they’re going to be, so this allowsus to evaluate, refine, and improve them, and

2. It provides a model that allows for best programs to really get out there instead of recreating the wheel at everysite.

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An Intervention to Promote

Climate Positive Behavior

• Human Biology 165 / EarthSystems 165: Spring 2007 studentsdeveloped interventions for courseprojects.

• Footprint analyses to select targetbehaviors:

– Size of Carbon Footprint – literaturereview

– Malleability – focus groups

• Survey to assess efficacy ofinterventions

We hope to follow a similar path. We did our initial formative work through a course that we co-taught this spring on

how to facilitate climate positive behaviors. In it, students learned about behavior change techniques and then

applied these principles by going into local high schools and developing an intervention for the students there. The

fields that we covered in class included consumer behavior, persuasion theory, communication theory, diffusion

theory, education, social psychology, and health promotion work. Several of the students have continued working with

us to revise them and we plan to implement a pilot study this spring.

Separate from the course, we performed footprint analyses that would help our students narrow down their possible

target behaviors, and would also to help inform other climate change interventions. To do this, we performed a

literature review to evaluate the footprint of dozens of behaviors – for example, the per minute impact of taking a

shower, of drying a load of clothes in the dryer, etc. We also performed an informal assessment of the malleability, or

changeability, of the behaviors.

Also separate from the course we developed a fairly comprehensive survey that we could use to assess the efficacy

of interventions such as ours. We’ve collected data on several hundred students so far, and are currently validating

the survey. We intend to make it public. [and are working on developing an abbreviated version, because the current

one contains about 130 questions.]

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Motivation Behavior Outcome

Facilitating This Process•Information/Persuasion•Observation•Enactment

Identify:External Motivators Internal Motivators

1Set GoalsEncourage New Skills and Habits

Address Barriers23

ProvideFeedback

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Based on Learning Theory,

Social Cognitive Theory, &

Cognitive Behavioral Therapy

A Theory of Behavior Change

Although we covered techniques from many disciplines in our course, several kept re-emerging as very effective

routes to behavior change. The fields that emphasized these the most were Learning Theory, Social Cognitive

Theory, Cognitive Behavioral Therapy, and Community Based Social Marketing. Although there is some common

origins to these, it is encouraging that these fairly distinct fields found similar techniques to be the most effective. As a

note, Social Cognitive Theory is likely the most frequently used behavior change theory ever.

This schematic is my representation of the core elements.

Learning Theory describes how individuals pair their behavior with an outcome – turning on the stove to generate

heat for example. Learning theorists held that all learning is acquired through first-hand interactions with the world.

Albert Bandura began as a learning theorist but eventually integrated a huge body of literature into a very

comprehensive behavior theory called Social Cognitive Theory. He describes how motivators can be external like

money or social approval, or internal like self-satisfaction or concern for future generations. He holds that behavior

change is predicated on strong motivation, but that alone is insufficient. One must have self-efficacy or confidence

that one can produce change. This can be increased by helping people address barriers, set goals, and practice new

skills. And, as before, feedback plays a role in reinforcing the new behavior.

Bandura took the model a step further – he said that there are different ways for this learning to occur, and some

ways are more effective than others.

•through information or persuasion, as with a PSA,

•by observing another person go through these processes

- which is what Mr. Ryerson spoke about,

•and through enactment. The latter includes first-hand experiences like the learning theorists described, but it also

includes imagining those experiences. This enables forethought, which is obviously critical when imagining climate

change scenarios.

Enactment tends to be the most effective, but it is costly in terms of time and mistakes. Observation is better in this

regard, and also for the fact that media can be used to model behavior to large numbers of people relatively quickly,

like with serial dramas.

Note too that targeting specific behaviors is very important because the specific barriers, goals, outcomes, etc. are

going to vary from behavior to behavior.

So I’m going to illustrate each of these points now with examples from our class projects or other real world

interventions.

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55 1L Balloons of CO2

Photo by Rod Golden

1.45 ounces of oil17 teaspoons of sugar

$1.50 x 4/wk x 52wks = $230 extra per year

Cause:Processing & Transport

Behavior:Drinking

Soda

PersonalOutcomes:

-$ & +Weight

Distant Outcomes:Lack of energy security,

Drought, extinctions, etc.

Oil & CO2

1. Identify Motivators &

Link Them to Behaviors

Proximal and personal motivators tend to be more effective than distant motivators. One of the groups in our classasked high school students “how many 20oz bottles of soda do you drink a week?” the average teen drinks more than4. When they computed out the yearly cost, it came to hundreds of dollars for most students.

They showed students that each soda contains 17 teaspoons of sugar which causes obesity (and grossed out thestudents).

When they covered more distant motivators, they tried to make these concrete and vivid. They displayed the 1.45ounces of oil which diminishes energy security, and the 55 1L balloons worth of CO2 that is released into theatmosphere. Then they had students blow up balloons to help them visualize this. (and just a note that 1 load oflaundry is over 700 balloons worth of CO2 at atmospheric pressure.)

The students also played Pictionary to understand in concrete terms why bottled drinks produce CO2 – fromagriculture, processing, and transportation - and what the effects of co2 and climate change might be - floods, massmigrations, drought, water wars, increased storm severity, animal extinctions, etc.!

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2. Address Barriers

External barriers• Infrastructure, technology

• Time, safety,

unpleasantness

Myths - When devices are turned off

they’re not drawing power; Turning

things off and back on

again uses more energy than

leaving them on

Cultural habits - 1996 study on

energy related behaviors in Norway

and Japan

Internal barriers• Myths & habits

•Perceived time, safety,

unpleasantness

Munster, Germany: 400,000 bikers/day

40% of daily transportation

There are different types of barriers. There are external barriers like infrastructure, technology, or issues of time,safety, or unpleasantness.

For example, Münster Germany efficiently mobilizes about 400,000 people each day, roughly 40 percent of dailytransportation. However, it is able to accomplish this through zoning, traffic laws, safety programs, marketing, andincreasing the availability of bike accessories to keep riders clean etc. This is an example of complementaryinterventions at different levels: at the policy, the physical environment, and interpersonal levels.

There are also internal barriers like myths & habits.

For example, regarding myths and misunderstandings, many people do not realize that when devices are turned offthey’re still drawing power. There’s lots more of these energy myths at the California Energy Commission andLawrence Berkeley Labs websites. [or they think that turning things off and back on again uses more energy thanjust leaving them on]

- Regarding habits, one study showed that Norwegians washed their clothes at 50 or 60 degrees Celsius, while theJapanese washed their clothes in cold water. Perhaps sharing practices between cultures could decrease highenergy use behaviors.

A large scale interpersonal intervention that works on addressing barriers that might be of interest to some of you isEnergyMark - a program run by Australia’s national science agency (CSIRO). It uses facilitators go to thousandsof homes throughout the country and sit down with people at their kitchen tables to talk about what has enabledthem to make energy efficiency changes, and what barriers they face. The facilitators provide tips to overcomebarriers, and share successful techniques with others.

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3. Set Goals &

Encourage New Skills and Habits

PracticeName_____________________________________My goal is _________________________________I will report my progress to my challenge buddy,__________________________ every ___________(a day of the week) during ________ (activity)

Something that might get in the way is ___________________________________________________I will deal with this by _________________________________________________________________Adapted from materials by Jane Rothstein, LCSW

Goals

There is literature showing that simply setting explicit goals produces changes in behavior. A simple activity the

students in our course used to set goals, and which is based on techniques used by cognitive behavioral therapists, is

to have individuals write their name, their goal, and a buddy they will report to on an index card.

Practice allows us to develop new skills and habits, and boosts self efficacy.

One group of students in our course developed a clothesline relay race to promote practice. Another group worked

with a local chef who is writing the book “Global Warming Diet” to come up with a couple of easy snack recipes made

from local produce and then had the high school students help prepare them.

It may be particularly useful to “break free” of an old habit and force oneself to practice the new one. In the SMART

TV intervention I described at the beginning of the talk, students refrained from watching TV for 10 days at the

beginning of the intervention. With driving, one could give their car keys to a friend for 10 days.

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4. Provide Individual Feedback

• 10-14% reductions in use

• Greater reductions withmore specific feedback

• Electricity Monitors inhomes

• Energy Monitors in cars

If you can count it, you can change it!

Sarah Darby. Making it obvious:

designing feedback into energyconsumption.

To provide feedback, the groups in our class had students keep simple logs of their behavior. However, electricitymeters in homes and energy monitors in cars can provide much more effective feedback.

In the area of energy efficiency, close to 40 studies were performed between 1975 and 2000 showing that simplyhaving a meter inside the home in a central location reduces energy use by between 10-14% on average. Up herewe have some current inexpensive devices for doing this – the Kill-A-Watt that provides feedback on a specificappliance, the central device shows overall home electricity use, and the energy orb on the right provides feedback asto the overall demand on the grid.

The second major finding is that the most successful studies were those that provided more frequent feedback, andalso feedback about specific behaviors. There are at least 3 companies currently working on wiring buildings or usingsmart technology to provide almost immediate feedback to a personalized website about specific rooms or evenappliances within your home. Then you can prioritize changes, and also find out when an appliance is so inefficient itneeds to be replaced, etc. And they are interested in potentially having this information feed into your cell phone sothat they can give you feedback like “good job” when you reduce your energy use.

There will also be a short talk on recent advances in measurement and feedback technology in the 8pm session thisevening.

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4. (cont.) Provide Group Feedback

Group goals & feedback

Competition

•One of the problems with climate change is that individuals wonder why they should bother changing their behaviorbecause alone they won’t make a big difference. However, this can be overcome with communal feedback. Whenresidents of the Midland-Odessa area in Texas were provided with daily evening television feedback and conservationtips, they reduced gasoline usage by 32%, and usage remained at 15% lower several months after the programcompared to what it had been prior.

•Competition can also be a strong motivator. Oberlin College has a Campus Resource Monitoring System websitethat compares the energy usage of all the dorms on campus on an ongoing basis.

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Motivation Behavior Outcome

Facilitating This Process•Information/Persuasion•Observation•Enactment

Identify:Internal Motivators External Motivators

1Set GoalsEncourage New Skills and Habits

Address Barriers23

ProvideFeedback

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Based on Learning Theory,

Social Cognitive Theory, &

Cognitive Behavioral Therapy

A Theory of Behavior Change

Today I covered a small but central piece of behavior change theory. Although I mostly focused on the level of

interpersonal interventions, using complementary interventions at multiple levels is important, as is assessing and

refining them.

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Relevant Fields

PublicHealth Entertainment

Education

Social Marketing

CommunityBased SM

ConsumerBehavior

CommunicationTheories

PersuasionTheories

BehavioralEconomics

DiffusionTheory

TechnologyDesign

Anthropology& Sociology

CityPlanning

Social,Cognitive,

& PerceptualPsychology

Marketing

Communication

Economics

Sociology

PublicPolicy

Medicine

Education

Furthermore, there are theories and tools to guide intervention work from numerous disciplines which, when used

together, will greatly enhance our effectiveness at changing behavior.