Findings: What’s Your Goal, and What Gets in Your Way?

Tuck professor Punam Anand Keller shares her years of research on barrier-based behavior change.

Hospitals occupy that liminal space in our minds where we store things like lifeboats and airbags: we’re glad they exist, but don’t ever want to use them. And, if you do end up needing a hospital, the last thing you want to do when you get out is go back anytime soon.

These are two unfortunate facts for people with congestive heart failure (CHF). Not only is CHF the leading cause of hospitalization in the United States, the rate of readmission within 30 days after hospitalization is one of the highest, at nearly 30 percent. While this is a massive inconvenience and acute health risk for CHF patients, it’s also extremely costly for the health care system.

CHF readmission rates are so high because patients have trouble with three things that keep them healthy: taking their medications, limiting fluid intake, and doing daily weight checks. For years, cardiologists have been lecturing their patients on the benefits of compliance, but to no avail.


Punam Anand Keller is the Senior Associate Dean of Innovation and Growth and the Charles Henry Jones Third Century Professor of Management.

Punam Anand Keller, the Charles Henry Jones Third Century Professor of Management, wanted to find a better approach. As an expert in social marketing, Keller differs from health educators in one crucial way: she doesn’t assume she knows what’s best for patients. “As social marketers, we say, ‘Let me understand what’s right for you and what gets in the way of reaching your goals.’ Those barriers are then used to design a customized intervention for the individual,” Keller explains.

For the CHF study, Keller’s customized interventions were three simple nudges: communication cards to enable health educators to better listen to and engage with patients; a list of frequently asked questions for patients; and a reminder magnet to enhance compliance. These easy, low-cost actions made a significant difference, reducing readmission rates from 19.8 percent in the matched control group to 13.8 percent in the intervention group. “We concluded that educational tools that facilitate improved self-care and overcoming barriers to recommended self-management for CHF have the potential to reduce 30-day readmissions and improve care,” Keller says.

The good outcomes of Keller’s CHF interventions are the result of what Keller calls “barrier-based behavior change,” an approach Keller has developed through two frameworks: ENABLE and MAP.


ENABLE is an acronym for “efficient, novel, active, behavioral levers,” and is an approach to social marketing communications and health interventions grounded in the literature of behavioral economics, consumer behavior, and psychology. In general, the goal of ENABLE is to increase active participation in initiating healthy behaviors. It does this through a set of 10 guidelines that stress dimensions such as low fear arousal, regret aversion, deadlines, status quo costs, and enhanced active choice.

For example, Keller tested ENABLE in six field studies about workplace wellness programs, some of which use financial incentives to encourage employees to do biometric screenings and engage in healthy habits around diet and exercise. Typically, companies try to persuade their employees to participate in wellness programs through communications that make employees afraid of being unhealthy. However, research has shown that fear can deter healthy behavior changes, while a boost in self-efficacy does the opposite. In light of that research, ENABLE “encourages employees to enroll by increasing their self-efficacy or confidence in undertaking healthy actions,” Keller says.

In one intervention using ENABLE, Keller identified barriers to getting a biometric screening—time constraints, privacy concerns, and difficulty making an appointment—and then designed an email campaign that avoided talk of health issues (to reduce fear arousal) and addressed each of the barriers, focusing on empowering employees to get the screening done. The ENABLE messages resulted in a 70 percent increase in the number of employees who completed the screening.


Whereas ENABLE is a tool to increase healthy behaviors, MAP is an approach to barrier-based behavior change that focuses on the decision-making process. Both tools identify barriers and use nudges to help people overcome them, but MAP is different in that it targets cognitive and affective biases associated with motivation, ability, and planning.

To see how MAP applies to a typical health decision, such as getting a flu shot, here are some challenges and their corresponding biases and nudges:

Challenge Bias Nudge
I’m fine as is (motivation) Optimism Increase the salience of costs
I will do it later (ability) Status Quo Reduce number of choices
This is too complicated (planning) Planning fallacy Give a reward to create endowment

Keller is currently working on a study for the World Health Organization that will aim to integrate nudges into school-based vaccination programs, using MAP as the organizing framework. There are many reasons why people hold anti-vaccination beliefs and attitudes, so a social marketer’s approach is likely to be the most empathetic and effective—understanding individual perspectives, and designing nudges tailored to those perspectives.

“I’m like a soldier who was trained to do this,” Keller says. “So of course I’m going to see if I can make a difference.”