Hi, welcome to the final segment of Health Behavior Change, from Evidence to Action. With me in the studio today, I have Yale students Tavi and Mariko, both students in public health. And today we're going to provide an overview of this entire course, and some of the things that we learned over the over the past few semesters teaching this class at Yale School of Public Health. So to remind you, a lot of this class came about in thinking about the general definitions of what health is. This was a class that was taught at the Yale School of Public Health, in Social and Behavioral Sciences. And the general goal was to teach people the social, and psychological, and behavioral foundations that contribute to health on the personal level, and also in the public health realm. And so the World Health Organization defines health as of the state of complete physical as well as mental and social well-being. So we really want to emphasize here that we're not just talking about physical health when we talk about the development or prevention of chronic disease. We also consider the mental and the social as being true foundations of what it means to be healthy. So recently, as we've discussed in class, we've shifted from emphasis on things like infectious disease or sanitation, and learning about and trying to really think about how to optimize public health. We've now come to realize that the social and the behavioral factors are part of what's contributing to larger public health dilemmas. So for example, we've come to learn that a large proportion of mortality is attributable to the things that we do, to things like poor nutrition, to things like smoking, and sedentary activity, and substance use and misuse. And at the global level, this accounts for about half of the chronic disease development. And so that's led some people to think about or to describe what we're doing now in the field of public health and where we should be focusing as the century of behavior change. That's where we should be right now. And so that's what this class was designed to focus on. And to also equip people with the skills to identify how to go about changing behavior, both on the individual level and, ideally, how to transmit that then to the general public health. It's a learning by doing type of approach. So what we know, the textbook definitions are that, for public health, is that we use education, try to develop healthy lifestyles. And we try to conduct research to promote program implementation, all to optimize public health. Now, what we've learned is that we are very good at educating. We know how to conduct research, and we know how to promote public service announcements, and these kinds of things. But education doesn't often translate to equipping people with the ability to use that information. So it's really hard to teach people how to follow health advice. And in fact, it's even hard for us, as the experts, to know how to follow health advice. Do you all have any experiences with that? We were just talking off-studio about one example. >> I definitely think that it seems very easy to to go, okay, I'm going to exercise for 60 minutes a day. And I'm going to make sure I'm eating the right things, and X, Y, and Z that we're always told to do. But I think, as students here, it can definitely sometimes be put on the back burner when we're focused on assignments, when we have extracurricular things that are really important to us. And so prioritizing our own health is not always something that I'm very good at, for sure, even as I'm telling other people. >> It's a very go big or go home environment. You're meant to do as many things as you possibly can, regardless of what the expense is, whether it's your sleep, your eating habits, your mental, physical well-being. >> Mm-hm, and I think that what you're describing now, while certainly, obviously relevant for the college student and the graduate student, extends all the way through every developmental phase in life. I mean, I hear the same kinds of things from people with young families, from people with children, from people with competitive careers, from people who are managing multiple jobs. It's always, I've got all these other kinds of things that I need to do, and yes, I know I should be getting up and eating breakfast. And yes, I know I should be getting adequate sleep, but look, I've got all these priorities. I've got all these other things that I need to be doing right now. And so we might have the education, but it's really hard to just do it as we're frequently told to do, yeah. >> Especially when we combine it with some of the structural and cultural factors that play into making it more difficult. When we look at that being able to follow health advice is definitely a privilege of time, it's a privilege of access. It's a privilege of having the money to make health advice more convenient. Because if you can buy a salad every day, great. But if you have to make your own food, if you're also managing other people's schedules, it gets increasingly more complicated much more quickly. >> [INAUDIBLE] a single parent trying to get enough sleep. >> Absolutely, right, all extremely important things that we have to consider as public health practitioners. And then another thing, even extending to the other direction, even when all of these things are lined up in our favor as an individual, it's just hard to do. Behavior change is extremely difficult. So we're making some progress in the field. Clinical psychology, behavioral psychology, and health psychology are all learning about how to best optimize or best teach people how to change behaviors. But there is a lot of conflicting information out there. And so this entire class was about trying to teach behavior change by doing it ourselves. So when we're teaching health promotion, just like how we're teaching anything else, what we've learned in education is that there's a hierarchy of how people best learn. And we know that lecturing, just kind of talking at large groups of people, is pretty ineffective, but that's the general model. And so going all the way through the hierarchy, what we know is that really learning by doing, practice by doing is almost as good as teaching others. And the reality is, once you are tasked with teaching others, then you really have to learn the material, right? So that's kind of a little bit challenging to do in a traditional classroom setting, or even in an online setting. But this practice by doing I really feel like is sort of the golden ticket of helping people identify how to change behavior, and also go to the process of doing it themselves. So that was the goal behind this class. So here's what we did. I want to back up a little bit and explain a little bit about what went on in the Yale course that I've been teaching at the Yale School of Public Health for the past several years. In teaching this course on behavior change and on social and cultural factors of public health, health behaviors, I had students pick a health goal and strive to change their behavior for one week. Identify a behavior change tactic, go through the process of trying to achieve that goal, and then identify any obstacles or barriers, any things that helped. And really, just kind of figure out how to do it themselves. And then they wrote about it, and they got graded on it, that kind of thing. And that went well, and it was well-received. But some of the feedback that came through, both in the projects and also in the course evaluations, was that the behavior change projects weren't really long enough. That people would have liked to have continued them for several weeks. They felt that just doing it for a week, they felt like, I can do anything for a week. I don't know that I really got as much from this as I could have, because I could power down and white-knuckle it for seven days, five days. And so they felt like we really weren't getting deep enough, we really weren't challenging enough. And then they also said, it worked really well when I knew that I was getting graded on this, and that I would have to talk about it, and that there was some accountability. But once the project was over, I didn't really have any incentive to keep it going. So I spent a long time thinking about that, and how to really turn this into something that not only would be an improved learning exercise, but that might actually benefit students. And so I decided, you know what, I'm going to do it for the whole semester. And I'm not only going to make them choose one goal, they're going to have to do it in four different domains. Because let's face it, health advice comes from all different directions. You need to watch your nutritional intake. You need to be sure to look out for your mental health and your mental well-being. You need to be sure to get enough physical activity. And, by the way, enjoy your social networks. So there's a whole lot of stuff coming in every direction. How about then if we live it for the full semester? Met with students, had focus groups, met with faculty, met with administration, got approval. Can I give extra credit to every single student in the class if they meet their behavior goals, the whole class? It might end up that I'll end up having to give perfect grades across the board, but with administrative support, would that be okay? Got the approvals, rock on, okay, we're doing this. Okay, so a whole lot of people, a whole lot of stakeholders involved. I was really excited about this, understandably, right? Okay, so kind of like a lived experiment. And then meanwhile, I also am speaking with colleagues in psychiatry right before the semester was starting. And I was all enthusiastic about this rebuilt course that I was about to launch. Somebody said, well, you're going to collect outcomes, right? I'm like, well, sure, I mean, I'll give them their grades. No, no, no, no, no, how will you know if it worked? I'm like, well, because I'll read their papers and I'll see if they learned. No, how will you know if their health benefited? Ding, ding, ding, my gosh, I can actually figure out what I really want to know, which is, does it help, is it any good? Will people's health benefit? So that's what we did. Again, wanted to use our knowledge as public health practitioners of how we use behavior change in clinical practice, in a medical practice to modify health behaviors. And we're going to do it on ourselves. We will be the subjects in our own projects. And then use this external motivation, a reward of extra credit. As it turns out, Yale students are really motivated. >> Excellent motivator. >> Excellent motivator. >> So people were optimized or incentivized to try to stick to their behavioral goals. The beginning of the semester, everyone signed a consent form. Everyone was informed, you have the option of taking part in this research project, if you so desire. People were not graded for being in the research project. That was very distinct. And this was what's called a quasi-experimental design, quasi-experimental because there was no randomization. I only looked at the health outcomes at the beginning of the semester, before anyone set their goals, and at the end of the semester. And so this design is limited by all the inferences that we can actually understand, which I'll discuss in a couple of minutes. But it still can give us a little bit of information. The participants were 91 graduate students enrolled in this class. It's one of these great, big lecture hall classes. And students did meet individually in smaller groups with teaching fellows to discuss things like overcoming obstacles and barriers. And choosing the behavior change strategy that would be the most effective for them. All right, we had some specific hypotheses. The paper was published a couple of years ago in the American Journal of Health Education. The hypotheses were, because we were focusing on four different behavioral domains, that students reported nutrition would improve at the end of the semester as compared to the beginning of the semester. Because everyone had set an individualized nutritional goal. Also, expected that students depression, anxiety, and stress would improve as compared to the beginning of the semester. And expected that students reported level of physical activity would increase. Okay, and why would I have expected these things? >> Because they're getting motivated with extra credit. >> There we go, right, people set goals to increase their physical activity, to do some kind of mental wellness behavior. And to choose some small modifiable nutrition goal, like eat breakfast. And then I also expected that students' general health would improve. So a global assessment of how good do you feel? What's your general health like, yes? >> And so this is all self-reported outcomes, correct? >> Correct, all self-reported, yeah, all self-reported, with surveys that are used widely in public health research and epidemiologic research. So I used validated instruments that are used in some of the larger-scale epi surveys from which a lot of the general health publications and research are derived. Great question, yeah.