Switch and text4baby — how can they be moved forward with current messaging technology

By Monica Guo and Nick Reid

We’re two health behavior change designers and we’re always looking for techniques and frameworks to apply to public health questions. We love public health, empowering health communication, brainstorming (omg post-its), and then sinking our development/design chops into building a tool that enables that. We find methods to help health organizations develop infrastructure to support health behavior change.

In our first efforts, we decided to read Switch, by Chip and Dan Heath, and to talk about how we could apply the lessons of the book to deepen our knowledge. One of the overarching questions we had while reading Switch, was how its ideas apply when we bring in other kinds of technology — as a brain exercise, we applied the ideas in Switch to a public health campaign, that we adore, that uses text messages: text4baby.

Switch is a book by the Heath brothers, Chip and Dan Heath, where they investigate what it takes to change human behaviors by using the metaphor of a person riding an elephant through the jungle:

• The rider represents a person’s logical reasoning, where they need information to decide which way to go.
• The elephant is a person’s emotional reasoning, which can become impossible for the rider to control without “gut smacking” motivation.
• Then there’s the path the rider and elephant are taking through the jungle, which could be either clear and well traveled, or hard to follow.

There are many different metaphors that explain the complexity that is a person’s behavior, yet we found the Heath brother’s metaphor worthwhile, simple to explain, and apply (unlike the transtheoretical model of health behavior).

The switch metaphor is useful for understanding how the interactions affects a person’s behavior change. Examples from the switch book are concrete, and pull from a large variety of contexts to illustrate how the elephant, rider, and path interact with each other.

Text4Baby is a well publicized and researched national health messaging campaign to promote maternal-child health with women expecting to have a child in the United States. We were able to find 35 messages from the Text4Baby campaign on their website, and used that as the corpus that we compared to the Heath brothers’ switch metaphor.

In our analysis, we codified attributes of messages from the literacy level of the message to how well the message appeals to a person’s rider or elephant. We did a combination of analyzing messages together, and coding messages separately. By comparing where our opinions differed, we further informed our results and discussion (ie this essay).

Here is the overview of our results:

• Tone: positive
• Message: informative
• Literacy level: low
• Call to action: not so great

It’s the last statistic, the call to action, that we’d like to explore more in depth. We consider the call to action a combination of:

1. appealing to the elephant in a message, and
2. providing a clear path.

During our discussion, we thought about many different factors that might have influenced a lack-luster call to action, and our thoughts solidified around two themes:

• Technical affordance provided by a text message campaign
• Individual nature of choices in maternal child health

Technical Affordance

Text4Baby was designed to have minimal input from the expecting mother. When a woman signs up for text4baby, she is only asked for the due date of her baby. The messaging campaign uses that date to set reminders and give updates about the baby’s development to the mother. Here is an example of each:

• Your baby can feel you dance & can hear lots of sounds. So play some music & have some fun moving together!
• It’s time for baby’s 1-month Dr.’s visit. Your baby had blood tests right after she was born. At this visit, ask your Dr. for the results.

These messages fit the switch framework well, as they give clear instructions to the rider, and make the path clear for both the elephant and the rider to follow. Many of the messages have engaging details that motivate the elephant.

However, the message below avoids details, and has a wishy-washy tone that appears in many other Text4Baby messages that we read:

• If you’ve breastfed for a year, you may want to keep going. You and your child will still get lots of great benefits!

What we wondered was, since some of the stronger messages are related to specifics, why didn’t text4baby leverage more personal information to create more tailored messaging? Currently, many technologies we interact with are hyper tailored to individuals — just look at the advertisements you see on a website like Facebook. Potential issues that might have prevented more personalized messages include:

• Allowing a mother to interact with a messaging platform by sending text messages back could be too much user burden
• Implementing data systems to custom tailor messages on multiple traits is much more difficult than simply scheduling messages
• Collaboration between content experts and software engineers to create dynamic content is difficult

What is clear after analyzing Text4Baby messages, is that much of the wiggly language could have been avoided with a stronger data model of the woman that text4baby is communicating with. Messages that reflect to the rider the current values of the mother are more actionable, and keeps the desired path clear and obvious.

Individuality

Sending messages that are tailored for each individual person is a neat goal if you can do it — and we saw messages from Text4baby that we thought could have branched even more to be tailored, if they could have known some more information. For example, if I can ask a mother if they’re currently breastfeeding or not, that changes the focus and tone of my message — if you’re not breastfeeding, we want to understand why, and maybe encourage it, whereas we don’t need to do that if a mother already is.

Text4baby seems like a program that can have stronger and more effective messages, if it knows its subsections of audience better. On the flip side, there were examples in Switch where this level of segmenting the audience wasn’t necessary, and a single message pushed out could have a wide influence. Let’s dig into this one a bit more:

Switch gave the example of a radio ad that encouraged everyone to change the milk that they bought to a healthier type. Impressively, this was something sent to the general population, and it seems like it worked well without segmenting.

Maybe the subject matter is just that different: buying milk versus feeding your own child, the second which is more emotionally-driven.

Although we all want the audience to reach the same goal, there are different paths that branch when we bring segmentation into play — and sometimes you can have a single path that’s like a straight arrow to the goal, and sometimes if you have one path for an entire group, some of those groups aren’t going to be able to travel it because they weren’t equipped the specific way to handle that path.

When the subject matter is complex, it’s hard to get content experts to agree on a specific issue. For maternal-child health, without segmentation, we see what text4baby did — writing messages that try to encompass as much of their audience as possible, across segments and diversity.

Our sense is that the Switch message about milk implicitly operates when we have a single path for all people to travel down. Text4baby was also sending the same messages to everyone, and it should be commended for the big task it’s responsible for: educating and supporting any expecting mother who uses it.

Certain messages and goals, though, could make more of an impact with mothers, if the messages were tailored — and we had that consideration that different people will need different paths, and drive different elephants (personally, Monica likes the Borneo elephant the most).

An example of tailoring a message in particular: we explored some alternative ways to phrase:

If you’ve breastfed for a year, you may want to keep going. You and your child will still get lots of great benefits!

• Some women breastfeed for longer than a year, and there is proof that baby gets lots of benefits.
• You have breastfed for a year! Keep going! You and your child will still get lots of great benefits!
• If you breastfeed for more than a year, you and your child will have great benefits!
• If breastfeeding still works for you and your child, you can keep going. You’ll both still get lots of great benefits! [link to resource of what kinds of benefits]

Closing Thoughts

Going forward, we hold the opinion that in order to support health behavior change, working to develop an infrastructure that allows for tailoring and speaking to different segments is key. The bigger question we’ll be chewing over: how do we — the big we — enable health organizations to develop the infrastructure needed to support health behavior change?

One thing’s for sure: turning context expertise into effective health behavior change is challenging.