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Don’t Knock the Nudge: Moving from online community engagement to real-life behaviour change in health

February 18, 2015

This is the third post of 4 in preparation of the #hccmty flipped panel by Robyn Sussel, Principal and Chief Strategist at

All 4 panelists will be presenting their ideas and sparking conversations on this blog so that the on-stage event at the February 25 #hccmty meetup will be but one more link in the chain, not the start or end point. Read the first blog by Colin Hung and the second blog by Blair Ryan.

For more information on the #hccmty event.

Eventbrite - #hccmty Meetup - Building Online Health Communities

By Robyn Sussel (@signalsca, @robynsussel)

headshot Robyn SusselWe all know that when it comes to human beings and behaviour change, offering the carrot not the stick usually elicits a better response. Think about weight loss advice from your doctor. “I think you should eat more fruits and vegetables.” Okay, yeah I can do that.  Versus,  “You need to lose weight so eat less!” Uh….not so much.

Nudging us towards better behaviour is clearly a better option.

Richard H. Thaler and Cass R. Sunstein introduced “nudging” in their 2008 book, Nudge: Improving Decisions About Health, Wealth, and Happiness. Their theory was that it is helpful to “hide” behaviour change in positive experiences.

A good analog example of “nudging” is this Stockholm staircase that was made into a set of piano keys. When given the choice between an escalator or a fun staircase, the healthier option wins out. People were not informed, preached at or even reminded of the benefits of taking the stairs. The nudge was just a better experience and they changed their behaviour without admonishing or shaming.

Much like the piano in Stockholm, online technologies offer health providers a chance to engage with people in ways that elicit action. We also know that all digital audiences are seeking better and meaningful experiences online. In my day-to-day work, creating these experiences is especially important for our health and human rights clients who aren’t seeking a “business” endpoint, like a financial transaction. But rather they are looking to educate and hopefully prompt behaviour change to improve health — which is often the hardest sell of them all. (I’ve written more about online nudging techniques on the Signals blog).

Having created many digital campaigns that promote behaviour change, I can tell you that online communities are often central to creating this offline change. But like Colin Hung said in his blog post from last weekend, creating an online community may not be the necessary goal. A good place to start is to really understand the behaviour of your audience (as well as their attitudes towards the subject matter) and also understand what communities currently exist that could potentially access these audiences.

For example, we created a campaign to encourage young women (age 19-21) to take a healthy action — to go to their pharmacy for their HPV shot. This was a campaign that sought to interact with a group of people who already interacted in many online spaces. So our strategy was to reach them where they already spent time. We also put the “sharing” experience in their hands so they could share their action with their peers in the communities where they were actively established. This encouraged peer-to-peer prompts for behaviour change — the “nudge” from their friends (not public health officials) to get the vaccine.

But there are cases where the right online community does not exist, despite evidence that the target audience is active online. We ran across this when we created the Power to Push campaign which was targeting women in BC of reproductive age.

Due to unacceptably high rates of c-section in BC (and climbing), the goal of the campaign was to educate women who had already experienced one c-section, that they didn’t necessarily need another one. More than that, the action we wanted them to take was to call and visit the BC Women’s Hospital clinic where offline interventions could take place.

At the time, there was no online community for pregnant women in British Columbia, so our strategy was to create one and “work in” the Power to Push message.  The “nudge” in this case was to provide women with an online support group that they lacked. Okay, contrary to nudging principles, we preached a bit, but it was mainly the community itself encouraging one another to consider alternatives to c-section.

The work involved in creating that community was huge (as my co-panelists have said) so this should not be taken lightly. But an economic case can be made — in this case our two year campaign was a drop in bucket compared to the savings to the healthcare system to avoid thousands of unnecessary surgical interventions. (Metrics for the campaign were presented at the first ever Evening Rounds in Vancouver back in 2012). Within a year it was (and still is) the largest online community for pregnant women in BC.

So here are some things to think about?

  • How could “nudging” help your organization bridge the gap from just offering information to patients/public to eliciting a healthy action?
  • How could “nudging” contribute to the sustainability of an online community?
  • How could “nudging” techniques be used to transition online community connections to in-person connections?
  • If you’re trying to make a health-related intervention, how can you best convince management that online discussion and to support to offline behaviour change is worth the investment (building a case)?

Panelists posts

13 Comments leave one →
  1. February 22, 2015 10:10 pm

    Robyn, as you mentioned, creating a community in order to support a public health campaign to change behaviour is a great undertaking in terms of effort, time and money. I’d be interested to know how you were able to convince the funder to assume those costs, especially to assume the ongoing costs of maintaining the community, which may have “outgrown” the funder’s original mission. If or when the rates of c-section births are reduced to the target level, will funding for the community end? Is there a succession plan, adoption plan or sunsetting plan for the community? I would hate to see the lights simply turned off.

    By the way, another great example of a successful community whose main purpose is healthy behaviour change is The Smoker’s Helpline Online hosted and funded by the Canadian Cancer Society.


    • February 22, 2015 10:36 pm

      Good questions Colleen. There is usually an appetite to keep the most successful communities going even when the money runs out. It most cases our communities are brought “in house”. To be honest “in house” for me is code for “sentencing to death”. But not because of bad will or anything nefarious. It’s just that maintaining vibrant communities require a good deal of effort. In house teams are not usually given the time they need to do a good job. Also, there is a skills gap. Usually communications generalists are given this task. We do train them but … Dot dot dot.

      And in some cases, not all, there is a tendency for the leadership to lose sight of the singular thing that bonds the community and start to pump out corporate communications. It’s because they see large numbers of followers or members and forget why they were there in the first place.

      The thing that drives me crazy the most about the Canadian health care system is that it is “penny wise and pound foolish” (my mom’s expression). They won’t spend $100,000 a year on a communications tool that has been proven to save $1 million in health care interventions. I’m hoping that engaging more health leaders through forums like the one on Wednesday will help to shed light on this issue.


  2. Shirley Williams permalink
    February 23, 2015 9:03 pm

    Nice post Robyn. As you highlight behavioural change in your post, I came away with the need to use both on and off line tools to facilitate the change. So perhaps it is a case of using cross media to help direct the change.

    Liked by 1 person

  3. February 23, 2015 10:16 pm

    Great post Robyn. Loved the piano staircase example. Behaviour change is extremely challenging – especially given the number of media/social channels that are available today. Yet paradoxically those same channels give organizations the ability to reach people like never before. Your Power to Push initiative is a great example of how new social tools can achieve a wider audience/level of engagement than previously possible.

    I’m curious, do you find that organizations are clear on their desired behaviour change at the start? or is this something that gets refined as the channels and messages get developed?

    Liked by 2 people

    • February 24, 2015 9:57 am

      In our case, we are usually engaged in order to make change. We work hard to make sure that the desired change is articulated and quantified at the beginning so we can measure how well it’s working. We do have a few “longer term thinking” clients who are attempting to build communities to facilitate culture as well as making small, consecutive changes that are not all thought out at the beginning. But usually, it’s very pre-defefined.


  4. Christina Lizaso (@btrfly12) permalink
    February 25, 2015 12:22 pm

    Great post Robyn. Love the staircase example. In the healthcare/cause world, it seems there are a lot of good, proven methods to raise awareness. Then there are less but still good methods to turn that awareness into education. But moving from education to action is just a tough nut to crack. In service-learning lingo of “What? So What? Now What?” it is the last one we get stuck on.

    I’m fascinated by what your group is doing. I’m also really surprised – pleasantly – that you got a whole community built to implement the Power to Push campaign. That could be such a powerful community to implement all sorts of important (and ultimately money saving) public health nudges. I was reading a post recently that while people generally make decisions based on information, people take action based on emotion. Making emotional connections through digital communities can help nudge behavior change.

    I think nudging could help sustain community in that can bring a benefit/outcome to being part of the community. And providing tools to share a healthy action and nudge others outside the community can help achieve the goals but also help the community member feel great about not only being part of a community but part of a change. Part of a community that is not just for its own benefit but is reaching out to make a bigger impact.

    Also +1,000 to going to where the target audience is already (IRL and online) and exploring the communities (IRL and online) that already exist. Showing where you targets are operating can help with making the case.

    I think community management work (like my base field of volunteer management) takes a special set of skills and is very hard work to do if you are wearing several other hats. It really doesn’t work well as an add-on duty. And a community building/community engagement mindset can’t be sustained without an organization-wide belief in its value and what it brings to the organization as a whole. You need that one person operating from that lens, but they can’t be the only one.

    Liked by 1 person


  1. Building Online Community in Health: Blockbuster #hcsmca-#hcldr-#eRounds Toronto Meetup | Colleen Young
  2. The Nature of Online Communities | hcldr
  3. “Is anyone there?” – Is your online community a ghost town? | Colleen Young
  4. #hccmty Event – Program Details and Livestream Wed Feb 25th, 2015 – Toronto | Colleen Young
  5. Is an online community really the brass ring you are seeking? | Colleen Young
  6. Five key components to building an online community for physicians | Colleen Young

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