Category Archives: Health

all things morbid and mortal

ABCs of Climate Change change

Consider this observation from a policy perspective piece in the New York Times.

But there has not been a huge public outcry to endorse new climate change policy. Polls consistently show that while a majority of Americans accept that climate change is real, addressing it ranks at the bottom of voters’ priorities.

You see the ABC, the Attitude Behavior Consistency, or in this case, the ABnotC, the Attitude Behavior not Consistent. Under many circumstances attitudes are consistent with behavior – you do what you feel and you feel what you do. And, we know that when attitudes and behaviors are inconsistent, that can produce Dissonance which nobody wants. We are highly motivated to be ABC when possible.

The Climate Change ABC we observe in the NYTimes quote is a problem of a different order. As we’ve seen with a lot of good experimental research exactly focused on Climate Change attitudes and beliefs, we find that for most Other Guys, their attitudes are weakly held and change with the slightest variation in the Local. Make a room warmer and Other Guys believe there’s more Climate Change; make a room cooler and they don’t.

Soft attitudes like that produce the ABnotC in the quoted paragraph. Other Guys poll strongly about Climate Change attitudes and beliefs, but when you poll them about behaviors, Climate Change policy moves drop to the bottom. Other Guy attitudes about Climate Change are so weakly held that when asked about political actions, other attitude issues like economics, jobs, immigration, gay rights, and so on, pop higher and stronger.

I’ll ask you now to reflect on this graphic from the ELM chapter in the Primer.

ELM Outcomes

Persuasion change can be assessed four ways: Magnitude, Persistence, Resistance, and Prediction. How much change? How long does the change last? Does the change resist counter-attacks? Does the change drive future action?

And, you’ll note from the graphic, a comparison between the two routes, Central or Peripheral with each of these change outcomes. While either an Argument or Cue based approach can produce the same Magnitude of change, you see differences between the routes on Persistence, Resistance, and Prediction.

Now, combine this persuasion knowledge with that original New York Times quote. Other Guys have favorable attitudes about Climate Change, but those attitudes do not persist, resist, and as we clearly see in the quote, do not predict action. The implication is apparent. Climate Change changers have achieved Peripheral Route, Cue-based change. All of the changed attitudes and beliefs about Climate Change are weak, contradictory, and vague in the minds of Other Guys.

If you are a Climate Change changer, you might understand this line of analysis and are probably explaining the outcome like this. The deniers are lying liars who are confusing Other Guys with those lying lies. No wonder Other Guys show ABnotC rather than ABC!

You may believe that if you wish, but such thinking both violates the Rules and fails a basic understanding of persuasion principles. Blaming the opposition for your persuasion failure violates the Rule:

Great Persuaders Don’t Need Kindness from Strangers

If you think that deniers are killing your case that means you are worse at persuasion than they are and that you can only be successful in persuasion when you have no competition. We’d all be professional athletes or actors winning all the awards if guys like LeBron James or Meryl Streep weren’t around, right?

Worse than the Rule violation, is the misunderstanding of persuasion principles. Other Guys do not necessarily develop weak attitudes because of competition and conflict between information sources. They primarily develop weak attitudes because they’ve been exposed to Cue-based Peripheral Route persuasion plays.

While Climate Change changers think they have been using science as the foundation of their persuasion, the persuasion outcomes contradict that perspective. If indeed the Climate Change changers had taken Other Guys down the Central Route with High WATT processing of strong Arguments based in science, then you would . . . what? Right. Look back at the ELM graphic. You would achieve attitude change that was persistent, resistant, and predictive. And that quote from the New York Times explicitly contradicts that conclusion.

Look more carefully at the persuasion plays from Climate Change changers and you see, not science as Argument, but science as Cue. You only need to see two words to catch this distinction: Scientific Consensus. Those two words have become the persuasion short hand, the headline, for basic Climate Change persuasion. Scientific Consensus.

As we’ve noted before, Scientific Consensus is not an Argument, but a Cue. The assertion that 97% of experts agree is not crucial information about the science of how climate change happens, its impact on humanity, or how humanity should respond. It is only a Cue that points to Authority, Dr. Doctor, Phd.

As long as Climate Change changers in particular and muggles in general miss this difference between an Argument and a Cue and the WATTage difference each requires, then you will always find a source like the New York Times making observations about your persuasion like the quote that opened this post. Everyone agrees with you, but no one will do anything about it. The persuasion failure is fundamental and begins with the source.

The practical lesson is . . . theoretical! If you don’t master the principles of persuasion then you will fail. Forget your passion or the importance of the issue or how many Fellow Travelers you can find or how much resource you’ve got. Bad persuasion begins with error and blunders on from there.

When your persuasion produces change that doesn’t produce action, you are failing.

Quilting versus Lumosity for Brain Games

Getting older? Losing your keys, your smartphone, your mind! You could save your mind with the science of Lumosity, brought to you in part by the Cardinal scientists at Stanford. Or you could just use plain old science. Like this.

Researchers recruited about 300 older adults (60 to 90 years old in good health) then randomly assigned them to 6 different treatment conditions, 5 aimed at mind saving and 1 a control. Before each condition began, all the Older Other Guys took a battery of standard measures of cognitive performance. They then went through 1 of the 6 conditions (5 treatment, 1 control) that lasted 3 months. At the end of 3 months the Older Other Guys took that same battery of cognitive performance measures. All of this took place in a local strip mall with a space called the Synapse Center.

This is called a pre-post experimental design in a one-way analysis of variance with six levels. It’s pretty good science with the largest weakness the absence of random selection of the original pool of Older Other Guys. It starts with a convenience sample of nearly 300, but then does science with that randomization to controlled conditions. Given the constraints of the practical world (it would cost a fortune to define the population then induce randomly selected Other Guys to participate) this is about the best science you can do in one project. What’s also very nice about this science is the number of treatments which provides comparison between competing variables, each assumed to have some kind of effect. Consider those treatments. Begin with 3 Productive Engagement treatments.

Photo condition
Participants were instructed by a professional photographer who trained them to use cameras and develop computer skills required to use professional photography software for photo editing. This condition was particularly demanding of episodic verbal memory and reasoning, given that participants had to remember many complex verbal instructions to use both the software and camera. On average, participants spent 15.84 hr (SD = 1.95) per week working on projects.
Quilt condition
The quilt condition had the same format as the photo condition and was under the direction of a professional quilting instructor. All participants learned basic skills and progressed to complete complex, individual projects using computer-driven sewing machines. On average, participants who completed the program spent 15.93 hr (SD = 2.55) working on projects per week.
Dual condition
The dual condition included training in both digital photography and quilting for 6.5 weeks each; in the final week of the study, participants could complete projects in either class. The order of the two types of training was counterbalanced across participants. The instructors were the same as in the photo and quilt conditions. This condition had more breadth of stimulation but less depth in each particular domain. On average, participants spent 18.11 hr (SD = 4.48) working on projects each week.

The Other Guys are not only thinking, but They are also doing what They are thinking. Thus, each condition is not simply acquiring information, it is using that information, too, but under thoughtful guidance with external feedback and standards, plus a strong social element with that class setting.

Now, 3 control conditions for comparison.

Social condition
The social condition mimicked a social club: It involved instructor-directed activities, such as cooking, playing games, watching movies, reminiscing, and going on regular field trips organized around a different topic, such as travel or history, each week. The social-group curriculum relied as much as possible on participants’ existing knowledge, with no formal knowledge acquisition. Games could be won largely by chance, with low requirements for strategy. The social activities involved no active skill acquisition. As in the productive-engagement conditions, participants in the social condition were directed to complete 5 hr of common structured activities and 10 hr or more of additional activities on-site with other group members each week. The social-condition participants spent an average of 15.90 hr (SD = 1.63) on social activities each week.
Placebo condition
For 15 hr per week, participants performed a structured set of activities that relied on activation of existing knowledge or activities that have not been reliably linked by empirical evidence to cognitive improvement but are commonly thought of as being cognitively engaging. Each week, participants were provided with an assigned packet of materials for 5 hours’ worth of activities (i.e., documentaries, informative magazines such as National Geographic, word games relying on knowledge, and classical-music CDs) and were asked to select at least 10 hr of additional activities from the “Brain Library” (a collection of magazines, DVDs, CDs, and crossword puzzles). Participants recorded the time they spent on the activities and visited the site for a few minutes at a scheduled time each week to pick up and drop off weekly assignments. Participants spent an average of 17.22 hr (SD = 2.50) on these activities each week.
No-treatment condition
Participants in the no-treatment condition were required only to complete a weekly checklist of their daily activities, which was dropped off at the research site at a scheduled time each week.

See all the great comparisons to the Productive Engagement tasks. Start with the no-treatment control; it functions as a secular time control, just seeing the non-intervention history of Other Guys. Social control obviously gives a comparison on the social dimension; maybe just hanging out with others in a group is the Special Sauce and you don’t need new learning. Finally, the placebo condition, which could also be called the Lumosity Plus Mozart treatment; no socialization here, but lots of cognition as you listen to all the notes Wolfgang crammed into a bar of music or as you play those groovy, colorful, and active brain exercises on Lumosity-like activities.

And remember, the battery of tests on cognitive performance before and after the three months of treatment. The tests measured four types of cognition: Processing Speed (sheer quickness of accurate responding), Mental Control (maintaining focus against competing sources of information), Episodic Memory (short term memory recall), and Visuospatial Processing (spatial short term memory).

Sincerity Sidebar: I sure hope you are still paying close attention and thinking with more than the Brooks Effect. Do you see the science here? Do you get the difference between press release Tooth Fairy Tales and this work? None of these guys called a press conferences and dressed up in a lab coat. This is science, kids. And if you cannot see the difference between this and that, then you deserve the panthering you are going to get every day of your life . . . back to the opera!

Quick summary. Older adults are randomly assigned to Nothing, Placebo (Lumosityness and Mozart), Socializing, Learning Photography, Learning Quilting, or Both Photography and Quilting. They are pre and post tested on standard tests of cognitive function: Processing Speed, Mental Control, Episodic Memory (short term memory), and Visuospatial Processing (perceptual). The treatment ran 3 months and about 15 hours each week.

Now, I’m going to hit you with a Pretty Picture that shows the pre-post change for each condition on the four cognitive measures. There’s a lot going on.

Saving Your Mind Fig 2

Orient. The color bars represent each condition. The size of the bar represents the amount of change. You see four panels, one for each cognitive measure. The horizontal lines with asterisks indicate statistically significant difference between the marked conditions. The y axis (the vertical of the graph) is the standardized change, the d effect size where Small is .20, Medium is .50 and Large is .80.

Begin by looking at the results for the Placebo condition which was essentially Lumosity plus Mozart CDs; it’s the orange bar on the extreme right for each panel. Notice that this condition is never the best and usually the worst at improving any kind of cognitive function. Note in particular that the Placebo treatment is the worst at Episodic Memory or short term memory, the key element in cognition.

Now look at Mental Control (top right panel). While all conditions showed a gain, no condition made a larger difference. Just being directed toward some kind of activity helped all the Other Guys improve their ability to focus on information even against a noisy and distracting background.

The primary good news is with gains in Episodic Memory (short term recall) for the information active condition of Photography and Quilting. In particular, the Photography condition shows a near Medium+ Windowpane gain in short term memory function which I find astonishing. The Quilting condition had a Small Windowpane effect and when combined with Photography, it actually reduced the short term memory advantage of the Photography training.

More generally you can see that the effects of any condition on any kind of cognition tend to be Small Windowpanes. You would need a statistician to detect these changes. Stated another way, if you watched any treatment group do a task and also watched the control group do the same task, you’d have trouble guessing which group did what. That’s a Small effect. It is there, but it is a change you have to count with fingers rather than a change you can see.

While the results on short term memory for the Photography training are Medium and obvious and statistically significant (!!!), I’m still wary. The tests are verbal which means the Other Guys read or hear a list of words then have to say or write them back either immediately or after some delay. A Medium gain here, especially with an average age of 70, is really strong.

I’d be worried about a detail like miscoding a test result for a couple of people or maybe just having a couple of outliers in the Photography group who had extremely low pretest scores and then woke up during the 3 months. Each condition had about 30 participants and outliers can really pop the mean. Consider a procedure called Winsorizing. If you dropped the highest and lowest scores in each condition and re-ran the analysis, the Episodic Memory would probably still improve in the Photography condition, but more like a Small Windowpane and not that Medium effect size. Stated another way, I’d really like to see the size of this effect replicated in other samples.

Past my Professor Poopypants pooposity, please see all the wonderful science in this detailed effort. This is work that makes a serious contribution to the literature, especially on interventions with cognition and the aging mind and body.

It’s important to note that highly active and involving tasks for the Photography and Quilting conditions produced more benefit than mere socializing and especially that FauxItAll Lumosity persuasive science, some from Stanford. Good grief, quilting can hardly be considered a revolutionary new activity made possible through apps ‘n iGizmos in the iPostModern World. Can anything be more old fashioned, your Great Grandmother’s Oldsmobile? People have been quilting for hundreds of years and it runs at least as good as Brain Games. Yeah. Technology changes everything.

You techie adherents may find joy with the Photography condition because it required the use of computers and software like Photoshop . . . which has been around now since 1990. Come on. We’re talking the PC revolution here not SM2.0 with Big Data and Big Analytics.

And that’s another reason I’m wary with the Episodic Memory results for the Photography training. That training is highly visual and procedural and is not word training in the sense of studying grammatical forms or poetry construction. You might obtain similar gains with a Furniture Making Condition. Perhaps it is working in a new world of highly structured concepts and actions that works here?

I’d be curious to compute the caloric expenditure for each condition. A lot of exercise research has demonstrated practical improvements in cognitive function from running or lifting or biking. The mind begins with the brain and if you work the brain with exercise, it maintains existing function and when restarted, exercise can activate old function. Perhaps the Photography condition required participants to get more exercise while taking pictures?

And, there goes Professor Poopypants, pooping all over the place. Let’s get out of here before we get pooped into oblivion.

1. This is science. Not persuasive science. Just science.

2. Moving the body and the mind improves cognitive performance. Not a lot of improvement, but it is improvement.

3. This took 3 months and 15 hours a week. Most effects are Small. Do you really believe that Lumosity a few minutes a day every now and then can have any practical effect? Heck even Lumosity with a lovely Mozart piano sonata for 3 months and 15 hours a week ran even with a pack of little old ladies and gentlemen in the quilting circle.

4. For you panthers working the jungle of aging Other Guys, you can still see the good news in the results. That Placebo condition did show pre-post gains. Put that in your next PowerPoint or Flash or YouTube. Independent researchers prove that Lumosity enhances your Episodic Memory, Mental Control, and Visuospatial Memory! Tell the truth! Just not the whole truth!

Finally. Read the paper. It’s good, hard work.

Denise C. Park, Jennifer Lodi-Smith, Linda Drew, Sara Haber, Andrew Hebrank, Gérard N. Bischof, and Whitley Aamodt. The Impact of Sustained Engagement on Cognitive Function in Older Adults: The Synapse Project. Psychological Science, first published on November 8, 2013


P.S. The best science to date on maintaining cognitive function across aging is . . . sorry . . . physical activity. Yeah, you can learn a new skill at the Synapse Center or fake it with a Brain Game, but if you want to keep your head on straight as long as possible, run, baby, run.

the Cold Pressor Persuasion Play©™® with John Cheever

You may know John Cheever’s name from an infamous episode of TV comedy series, Seinfeld, where everyone discovered that George Costanza’s father-in-law had had a brief gay fling with Cheever as revealed in a box of letters, the only surviving item from a cabin fire set from Kramer’s Cuban cigars. John Cheever was a great writer who received a Pulitzer Prize in 1979 for his book of short stories. He was also a persuasion theorist.

A family is meeting at their summer vacation cottage on the Atlantic in New England. Like most families, there remains ancient tensions between adult siblings and one in particular drives everyone else to frustration. Yet, as Cheever the persuasion theorist reveals, they stumble upon a persuasion play as this paragraph narrates.

And now I remember that while Lawrence was visiting us, we went swimming oftener than we usually do, and I think there was a reason for this. When the irritability that accumulated as a result of his company began to lessen our patience, not only with Lawrence but with one another, we would all go swimming and shed our animus in the cold water. I can see the family now, smarting from Lawrence’s rebukes as they sat on the sand, and I can see them wading and diving and surface-diving and hear in their voices the restoration of patience and the rediscovery of inexhaustible good will.

Goodbye, My Brother, page 10, The Stories of John Cheever.

This, of course, is a variation on the cold pressor task so beloved of behavioral researchers. Just insert your body or a part in freezing water. If you’ve never fallen into a winter creek, you have no idea how compelling the cold pressor task is. It dominates you like Mike Tyson back in the day.

Typically the task is employed as the first independent variable in a study. You complete informed consent and stick your arm in that bucket. Then after a bit, you do something else, most often the dependent variable, such as watch the monitor that shows your blood pressure elevating like a rocket. Here we see Cheever as theorist perceiving the cold pressor task as something that modulates an existing condition. When unhappy Other Guys willingly go for a swim – which is a cold pressor task – they will emerge from the freezing brine with a new and favorable attitude!

The trick here is to get the Other Guy to willingly engage in a cold pressor task. Cheever’s argument is that if you can get her willingly in the water, she will change. Sure, you can get compliance in the lab with money or credit, but in the Local called the mess of life? This, of course, is where we separate the mavens from the muggles.

Here’s how I’ve done it with Melanie.

I use this persuasion play when it is either raining or cold and we’re having an argument. We’ve gotten stuck in the mud of grievance with neither party having the willingness or ability to turn the other cheek which means a Long Night ahead. So, I dare Melanie to take off her clothes and run around the outside of the house, naked, with me. As I make this dare, I strip. Melanie cannot resist a dare and also finds the sight of me naked and unmanned to be funny. By now she is undressing and giggling and putting on a pair of sneakers, then we’re out the door. I surprise her, I challenge her, and, sigh, I amuse her into the cold and wet.

I wish we’d learned the Cold Pressor Persuasion Play®™© when we were first married. Then we employed all the conflict management tactics from the interpersonal communication and human relations and counseling literature. Lots of listening. Active and reflective listening. Perception checking, I hear you saying. Descriptive feedback. Yada-yada. Still produced a lot of Long Nights. Racing your naked spouse in the rain around the house on a cold night works much faster.

Now, we have lived almost all of our married life out in the woods with no neighbors nearby. If you live in the city or a tight suburban tract, you might want to think carefully about running outside your house naked with your significant other. You might modify this play to include squirt guns filled with cold water for example. Or jumping into a cold shower together. That’s your challenge. As the Rule says:

Drive with Science, Putt with Poetry.

The science of the Cold Pressor Persuasion Play©™® demonstrates that it really changes the Other Guy, but the poetry of the play is getting her willingly wet. Now, if I knew the circumstances of your Local, I might be able to make suggestions, but do you really want me to know you and yours that well?


P.S. What’s great about the science of the Cold Pressor Persuasion Play©™® is that even when you know why you are doing it, it will still make a change you can count on. Often awareness of the persuasion principle kills the play; not with this one.

P.P.S. This is a type of Embodiment Persuasion effect. Change the outside to change the inside.

Pedaling Persuasion

While dreaming of persuasion . . .

Smoking tobacco is the single biggest risk for premature morbidity and mortality in the US. While a small percentage of smokers will show few negative effects, most smokers will die 8-10 years sooner than nonsmokers and with many more preceding years of ill health.

Smoking is also a blast. You look cool as hell. You get to use cool as hell gadgets. You get the thrill from the nicotine. You create fabulous moments as when the glow of the cigarette illuminates the curve of your lover lying beside you.


Biking is the most dangerous form of personal transportation in the US. Biking takes a trivial amount of both transportation time and distance, but accounts for 2% of transportation fatalities.

The 677 pedal cyclist deaths in 2011 accounted for 2% of all traffic fatalities during the year.

And as bad as that is, biking kills at much younger ages, even younger than smoking. Biking is overwhelming attractive to the same kind of personality that like to smoke, males who like risks. You see that in the fatalities, almost always men who have safer options but pick biking instead. Consider this appeal for a charity bike run.

Assault on the Carolinas

Biking is also a blast. You look cool as hell in those bad black spandex outfits. You get to use cool as hell gadgets. You get the thrill from the pump. You create fabulous moments as when the glare of an on-coming headlight illuminates the curve on which you will die.

Like smoking, biking is a public health menace and should be banned.

Hey. How come bikes aren’t inspected every year? They run on the same roads as cars. How about this? Require odometers and usage clocks on all licensed bikes. We can collect good data (maybe even Big Data!) on actual usage then have a better base rate to run fatality and injury incidents against. Who is against a scientific study that counts the change with usage and biking death or disability?

Still not convinced? Let’s try this persuasion.

In 2011, 677 lost their lives in bicycle/motor vehicle crashes, just under two people every day of the year in the U.S. While lower than the 732 fatalities in 2001, this number represents an increase from the 618 bicyclist fatalities reported in 2010.

Now. Compare that to this.

In 2010, unintentional firearm injuries caused the deaths of 606 people.18

More people are killed in biking accidents than in firearm accidents! And more people have accidental “access” to guns than have accidental “access” to biking. Think about it. Best guess is that about 40% of American households have a gun in them which means a possible gun accident every day for over 125 million household occupants.

By contrast, a recent population survey of bike riding found 18% of people 16 and older rode a bike at least once in the year which means at least once a year 60 million people were at risk of a biking accident. Please model out however you wish those 60 million people and how many days they biked. But by any count it will be less than the daily exposure to a gun in the house with 125 million people. Yet the number of deaths are almost equal. At minimum given the numbers on exposure we’ve got here, accidental deaths from biking are at least twice as high as from gun, a near Medium Windowpane.

We need gun control (that cannot get passed for a variety of persuasion muggle reasons), but for a risk that is at least twice as large as the risk of accidental death from a gun, people demand more biking!

. . . awakening I wonder whether I’ve been dreaming or have just opened my eyes.

Finding the Tea Leaves with ObamaCare

After a bad start, Team Obama hit its public number of 7 million enrollees in ObamaCare. Some insiders are now talking about the persuasion campaign. Consider this question and answer.

Q: Think at the 60,000-foot level about the way history books talk about presidential administrations and how they have problems and confront them. Are there lessons about the mistakes made?

MR. MCDONOUGH: Look, I’m a person with a very active conscience. But I’m not going to bare that to you today. I’ve done a lot of thinking about that . . .

. . . The third is something I’ve been saying ever since October 1, which is the strength is in the planning, not in the plan. There’s never a plan that you run in the government, and I don’t know, maybe the private sector, that survives first contact.

McDonough maintained operational leadership of the persuasion campaign and his perceptions are crucial to understanding what happened. And, like a good panther, he’s not going to tell us anything about that. He has a “very active conscience” which sounds like the beginnings of a confession, but then the cold heart of a panther kicks in.

McDonough does imply a key point we’ve been featuring in the continuing analysis of the ObamaCare campaign: Planning. Giving his response, I believe that McDonough believes Team Obama did a poor job in planning, but not in the sense that they failed to write a book called the ObamaCare Persuasion Plan – they did – but because they assumed the plan would work once it became operational.

To me that suggests Team Obama failed to count the change at key steps along the operation, just assuming that The Plan was working without gathering data along with way. Only until The Plan failed massively did anyone realize that they were not checking it. Some folks make a distinction between process evaluation and outcome evaluation. Process evaluation counts things related to the campaign operations – how many minutes of media time have aired, how many print ads have gone out, how many hours of volunteer time on the phone. Outcome evaluation counts primarily the TACTs – in this case the number of enrollees.

McDonough’s response can be understood as marking a failure in process evaluation. Team Obama just let the Plan rip and waited to count the enrollees instead of counting the process markers which would have revealed problems much sooner.

Or not.

Again recall McDonough’s line: “But I’m not going to bare that to you today.” He’s still not telling the truth, the whole truth, and nothing but the truth and in so not doing, maintains his panther status. In other words, we still don’t know precisely why things went sideways so fast and then recovered so well. Nobody writes honest confessions about practical persuasion. Honesty makes you too famous.

The politics of ObamaCare muddy the persuasion waters. Everyone’s got a position on this issue and that biases everyone’s analysis. You can only draw your own conclusions and work from there which is another way of saying you need a lot of salt, lime, and tequila when you read my take on this.

Regardless of the politics of ObamaCare, I perceive it as a badly failed persuasion campaign that could have and should have been a success given the resources available. McDonough’s observations about the Plan versus Planning indicate to me that a lot of persuasion idiots had input to the Plan because only persuasion idiots think their Plan will need no Planning once it hits the ground. What I call the First Campaign failed.

And while the Second Campaign hit the magic number, it is obvious that the number is magic. You can use it for the politics, but if you count with the cold persuasion heart of a panther, there’s not much change to count. All the independent data on ObamaCare enrollees indicates that a smaller proportion were the crucial targeted Other Guys – previously uninsured and healthy adults. A larger chunk of the 7 million were either previously enrolled in a health insurance plan or else were uninsured and unhealthy. And, we’re still facing nearly 40 million uninsured adults who now face fines for noncompliance. Whither Nudge?

And, you can see the failure in ObamaCare with the active presence of the Third Campaign operating with a number of Democrats up for re-election. Several Representatives and Senators who voted for ObamaCare in 2010 are now availing themselves of wiggle room as they confront an electorate with a decidedly mixed opinion of the law. Those politicians are now running the Third Campaign that permits them to be both for and against ObamaCare now. If the persuasion campaign had been a ripping success, everyone would be shouting ObamaCare Today, Tomorrow, and Forever.

Now think of the hundreds of millions of dollars that were available for this campaign both from the Fed and Big Insurance. This was one of the largest and best funded persuasion campaigns aimed at behavior change ever created. It’s been in the works since 2010. This is like doing D-Day in World War II with Saving Private Ryan and not like responding after the sneak attack at Pearl Harbor. Team Obama had everything it needed to launch a successful campaign.

McDonough only hints at the practical problems in this persuasion failure at that Plan versus Planning distinction. We are left to read the tea leaves which means different panthers will see different lessons. Politics passed the law and left it to persuasion to implement. If you ever wondered at the difference between politics and persuasion, you now have a great example.

When 0.03% Is A Lot . . . of Sincerity

Consider the news.

CBS Kids Guns

Guns hurt kids! A lot. Nearly 20 hospitalizations a day just for kids hurt from guns!

“These data highlight the toll of gun-related injuries that extends beyond high-profile cases, and those children and adolescents who die before being hospitalized,” Dr. John Leventhal, a professor of pediatrics at Yale School of Medicine in New Haven, said in a press release.

And this.

Dr. Georges Benjamin, executive director of the American Public Health Association, told HealthDay that people do not realize how common firearm injuries are.

Well, just how common is common? Consider the table of data that launched this ship.
Kid Gun Table

Note first that circled number on the lower right, 7391. That’s the number of hospitalizations for kids up to 19 years old for gun injuries in 2009. The article persuasively provides no base rate here and only works the numbers in its database. Let’s do some comparing with those 7391 cases.

In 2009 there were about 34,000,000 total hospitalizations for Americans. So, divide the kid gun injury number by 34,000,000 and you get:


Now one percent is written as:


So 0.0001% is considerably less than just 1.000%. But, that mixes kids with everyone else including adults and for all causes. Let’s use another base rate.

In 2009 there were about 3,000,000 total hospitalizations in the US for people under 21 (21 isn’t 19, but I cannot find a source that defines “kids” as 19 and under). So, divide the kid gun injury number by the total hospitalization number for all kids and you get:

0.002% hospitalization rate for gun injury in 2009 for kids compared to all kid hospitalizations.

One percent would be:

1.0000%. The rate here is:


That’s how common it is for a kid to be hospitalized in the US for a gun injury compared to all kids hospitalized.

Now, let’s consider the numbers yet another way. Look at this table from a different source that looks at all kids (again under 21) and their cause of hospitalization in 2009.

All Kid Hospitalization 2009

Note at the top of the graph the line for totals in the injury and poisoning category. It’s 287,000 cases for any kind of injury or poisoning. Remember the researchers found 7391 gun injuries. Let’s divide that by 287,000. That’s about 0.03% of this tighter category called injury and poisoning.

In summary for 2009, 34 million people got hospitalized, about 3 million kids got hospitalized, about 300,000 kids for any kind of injury or poisoning, and if we include criminal acts for kid gun injury, we get 7391 cases. Gun injury in kids accounts for:

0.0001% of all hospitalizations.

0.002% of all kid hospitalizations.

0.03% of all kid injury and poisoning hospitalizations.

And that is a “common occurrence.”

I’ll let you peruse the original research table for details about different categories of age (considering 19 year olds as “kids,” for example) and cause of injury (assault versus unintentional, for example). Calling all these 7391 cases as innocent kids struck down by guns seems to require liberal use of the General Semantics Persuasion Play©™®. Remove those 60% of cases caused by assault, and the rate of hospitalization for preventable (accident, suicide, undetermined) gun injury gets even less than 0.0001% or 0.002% or 0.03%.

We can all agree that injury is a bad thing, especially in younger people. But, when you realize that even with a generous definition of kid and including criminal causes for the injury, the rate of hospitalization is incredibly small. The persuasion implication now is the continuing persuasion incompetence of gun control advocates.

Here the advocates are wearing white lab coats, trying to appear as concerned, but objective, experts. They design a needle-in-haystack database then headline they’ve found a needle factory when they are only distorting words to mislead about numbers. And, if you read the comments to the CBS news story, you see the skepticism among the readers, even beyond the knee-jerk politics. While this is supposed to be irrefutable science, it is nothing but another way to polarize Other Guys.

If you are a gun control panther, you need to do something about the American medical community. They are killing any chance of effective persuasion. They persist with bad science that everyone can see and that only antagonizes or alienates the Other Guys they need to change. They engage this faux science of bad counting and try to fool people with false precision and white lab coats. That gets headlines and creates no persuasion.

The Rules.

If You Can’t Succeed, Don’t Try.

All Bad Persuasion Is Sincere.

It’s about the Other Guy, Stupid.

Consider this if you desire federal gun control legislation.

Convene a prawns ‘n plaques conference and invite all these ineffective Sinceres. Praise them to the heavens. Give them awards. Individual awards. With their names spelled correctly. Let them speak for as long as each wants upon acceptance. Ask them to speak directly about their values on this issue. Now serve prawns with a lot of bread and wine.

Then invite them into a secret society that pledges silence to let anti-NRA vampires, panthers, and werewolves go to work with the promise that they will reconvene in five years to consider the changes. Promise to publicly revoke the award and rebuke the holder if anyone breaks omerta. Then have a plant deliberately speak out a few months later and put the hit on him. Then he privately recants his failure and you give back the award.

If you could get these Sinceres out of the way for five years, you might actually get some federal gun control legislation passed and with red support. With these Sinceres in the room, all the Other Guys are wary and skeptical and mistrustful of any proposal because they rightfully believe the Sinceres would repeal the 2nd Amendment and outlaw guns. With these Sinceres silent and on the sidelines, you can follow the NRA playbook in reverse and get some persuasion going.

Start here. Did you notice in the last graph how many older kids are hospitalized for mental and emotional illness? From ages 10 to 19 nearly 300,000 were admitted for just that single cause in 2009. Are there no implications for violence prevention there? Nearly 40 times as many kids are hospitalized for mental and emotional illness as from gun injury. Do you see a neutral common ground?

Of course, if you are a wily gun control panther, none of this really matters. You can do your business with or without Sinceres as long as you don’t care about the outcomes of gun violence. We are beyond good and evil and as long as you can count the change you most desire, it’s all good persuasion!

a Climate for Failure with Cool Tables

Climate Change changers provide a compelling, useful, and on-going case study of persuasion failure. Everyone knows the sky is falling and knows why the sky is falling and how to stop the sky from falling, yet no one is doing anything to stop the sky from falling. This can only occur if you are lousy at persuasion. (Or lousy at science, but let’s concede that for the moment. The sky is falling, we know why, and we can stop it, but we don’t.) Why this persuasion failure?

We’ve looked at numerous examples in the Persuasion Blog, but they tend to be specific and focused examples that ignore the broader sweep and scope of Climate Change changers. I’ve now found a helpful source that traces the Local of Climate Change changers almost from the beginning through at least 2012. The authors are participant-observers, that is, both academic researchers trying to understand the Other Guys while also being part of the Other Guys themselves. They believe in Climate Change and they are also curious about how the thing works, or in this case, doesn’t. They provide that sweep and scope in a qualitative analysis of this persuasion case. Let’s begin at their end.

In closing, our study contributes to understanding why, despite the widespread agreement on the urgency of mitigating climate change and of developing adaptation mechanisms, powerful actors still seem unwilling and unable to subscribe to a single course of action and to provide an effective solution.

Thus, these insider researchers, who’ve participated in most of the major UN sponsored meetings, believe that the Climate Change changers have failed. They have not persuaded key Other Guys to do anything useful for solving the problem. So, in this research report, published in a peer review journal, people who are qualified observers (and believers) report on their observations of the major source of Climate Change persuasion, the various United Nations groups, the players working in that context, and the characteristics of that Local. Consider this foundational observation.

Hardy and Maguire (2010) argued that field-configuring events can catalyze change because they provide discursive spaces not normally available: they are temporally bounded, special moments in the life of a field and facilitate interactions among field members that do not usually interact.

Translated into practical persuasion this means people combine into large transnational units that can change the world through the use of communication (discursive spaces that facilitate interaction) among members with deadlines (temporally bounded, special moments). More compactly: Cool Tables with time limits.

While transnational units exhaust the universe for communication Locals (unless E.T. is out there), you can still apply this idea to any setting where all the Other Guys can be divided into smaller segments of groups. In the Fed, I lived in a Local segmented by branch of government (Executive, Legislative, or Judicial), then within branch, different Agencies (Defense, Commerce, Labor, HHS, and so on), then within any Agency, many different Centers, Institutes, and Offices, and on and on with the Fed organizational chart. Even if you are living in the Local called a Mom and Pop business, you can segment by customers, suppliers, and so on. In other words, the transnational nature of this Local is big, but still just different groups of Other Guys in the Local.

You then construct Cool Tables and populate them with representatives from the various segments. Now add time limits for their interactions. And, while they are communicating, they are communicating in discursive spaces which means everyone gets their turn at the microphone while everyone else (theoretically) listens. Such interaction will cause everyone to understand everyone else, discover areas of agreement, and through the pressure of known and shared deadlines, will create action. While not made explicit in this paper, I also believe the central motivating force behind all this is that irrefutable, irrevocable, and irresistible science. The Apple is Falling.

I’ve seen this work before.

Just as I was joining NIOSH in the late 1990s, they had completed a nationwide series of town hall meetings with anyone remotely interested in workplace health and safety. From these meetings, NIOSH developed a list of specific areas for research which had widespread concern and support. They refined both the items and their wording by forming content committees who discussed a specific area in depth with those Other Guys most concerned about it. From this iterative Cool Table operation emerged NORA, the National Occupational Research Agenda.

NIOSH leadership then took NORA to the President and Congress and got the best kind of change you can count: Funding. NIOSH got the funding because of the Cool Table operation. Other Guys who participated in the Cool Table town hall meetings or committee work called the President or their Congressional representatives and persuaded for both NORA in general and their specific area in particular.

The people behind the play knew what already existed, but let the Other Guys on the Cool Table discover it for themselves in public. This process not only let the Cool Table show off, but also built a natural constituency to advocate, support, and work the research area. The Cool Table also functioned as a reliable source of public knowledge and its distribution, so that over time almost everyone with even a minimal interest in workplace health and safety knew about the Cool Table and its operations. You can use the Cool Table as a sleeper hold, as I often recommend, but you can also use it to make things happen.

So, you can combine large and diverse groups of Other Guys, glide them into discursive spaces with plenty of time at the microphone while a clock is running and you will get both ideas and action that then leads to the big change you want to count.

It. Does. Work.

Why not with Climate Change changers? The researchers offer four detailed observations explaining why things with the UN Climate Change changers have failed so far. We’ll take them one at a time.

. . . we find that field-configuring events over time ceased to be interactionally open and temporally bounded as diverse actors with vested interests entered the field, power coalitions shifted, and the events became platforms for issues not strictly related to emission reduction. Under such conditions, the deliberate staging of the Copenhagen high-stakes event in 2009 to induce a sense of urgency in the climate negotiations prevented institutional change and resulted in an ongoing delay of substantive policy decisions.

Stated in persuasion terms, the discursive space became so open and so crowded that nothing got done. When planners realized this, they gambled on a “high stakes” Cool Table meeting in 2009 at Copenhagen that forced everyone to either work together . . . or not, as it turned out. Self interest usually beats Other interest.

Realize that Cool Tables should operate with tight control of who gets in. This quote explains that the UN process lost that control and just about anyone who was both noisy and rude could push into the Cool Table. Sure, there’s the dynamic tension here of being open and democratic versus enforcing rules from an open and democratic process. The UN changers failed to keep the Cool Table closed and defined as they practiced eternal open discursive spaces.

Now, this.

Because an overarching authority is missing in transnational fields, rules, norms, and understandings are continuously (re)negotiated and often highly ambiguous to include diverse actors and logics (Djelic & Quack, 2011).

And we know why the UN changers failed to keep the Cool Table closed and defined. Nobody had sufficient power or persuasion to enforce any interaction rules in the open discursive spaces. Even after the Cool Table first met and defined rules, no one enforced them and worse still, the Cool Table got bigger and bigger with more frequent rule violations and abuse of open discursive spaces. The consequences here are both obvious and destructive. Yet, no one did anything about it. Why?

I take recourse to the Rule of There Are No Laws and you see that here. Why did no one in this UN change process cowboy up and enforce rules, discipline, and focus? Who knows? The UN is always haunted with a lack of power whether in terms of guns and money or political legitimacy. It lacks sovereignty. But, even past that, if you’ve watched enough John Wayne movies, you know that one guy can stand up in the crowd, enforce justice, and things work out. Why has there been no one guy or even on small group of guys who rode herd on the rest to enforce the rules everyone had made?

And, it’s not like this oversight requires a horse, a gun, and the Duke. During the NORA process, NIOSH leadership had some power with money and access, but nothing decisive. However, that leadership controlled those town hall meetings and committees and locked down entrance and exit. They persistently kept to the public rules of NORA and enforced them personally, not with money or access. They just ruled both formally and informally the way effective group leaders (and persuaders) do. Apparently no single person or group in the UN process has ever operated like this. Stated another way, there’s no leadership in the UN Climate Change changer process.

So, here we are in our open discursive spaces, jibber-jabbering without fear of consequence, eating time while watching the clock count down, each pursuing our individual interest. Guess what happens?

. . . our findings suggest that the effects of field-configuring events are closely tied to emotions, so that analyzing such events can enrich recent efforts to understand the emotional dimension of institutional work (Voronov & Russ, 2012). Ritualistic performances afford shared emotional experiences and are often deliberately crafted to that end (Dacin, Munir, & Tracey, 2010); social movements partly gain their mobilization potential from emotions such as passion and feelings of solidarity (Flam & King, 2005; Goodwin, Jasper & Polletta, 2001; Goodwin, 2007). At the same time, our study has shown that heightened emotionality can also obstruct change under specific field conditions.

While certainly true of human nature, this observation damns the UN change process as little more than a pecking party. In the midst of doing science-based public policy, the UN change process permitted emotionality to dominate the discursive space. Of course, people will get fired up on big issues that personally involve them. That’s known and given. Any change process that does not recognize and control this only indicts its own incompetence. Here you see the flip side of the Wisdom of the Crowd. Crowds tend to encourage emotionality as they rampage down either the Peripheral Route or the Biased Central Route.

The Cool Table devolved into the Mob. An elite Mob. A scientific Mob. A sincere, passionate, and committed Mob. But a Mob.

When you have open discursive spaces and no one enforcing any kind of rules, you will soon get the Crowd at the Cool Table. Anyone who has worked with groups of humans at any age knows that groups without enforced norms of conduct will devolve into source material for the next version of Lord Of The Flies. No cohesion. No focus. No product. Just a lot of discursive open space filled with self interest and emotion.

And, especially when you point the Cool Table in this direction.

The field of climate policy is an extreme case of a transnational field, because the need to substantially reduce greenhouse gas emissions not only mobilizes governments, international and nongovernmental organizations (NGOs), private sector actors, and research institutes all around the world (Orr, 2006), but also requires that millions of organizations and individuals change their production and consumption patterns, which implies a changed economic system for a threat that lies largely in the future (Giddens, 2009; Levy & Egan, 2003).

We arrive at the Ground Zero for this case study failure. This is the TACT statement. This is what we want all the Other Guys not at the Cool Table to do. The Target Action Context and Time. The Who does What Where and When.

Can you believe the scope and range of this TACT? It is absurd on the face of it, a massive leap of faith while doing science. Gee. Imagine that it is difficult to get 6 billion people to agree on the same threat and same solution that involves changed national and international economic systems? I realize that there are also much more specific TACTs in the various UN IPCC statements, but the general structure is both so vague and so wide as to strain common sense. Who thinks like this?

The cluelessness of this orientation to the TACTs exposes the wide ranging incompetence and inexperience of the UN Climate Change changers. They think they have irrefutable science that will motivate and discipline Cool Table representatives to restrain their human nature, emotional responding, and self-interested biases, play fair and nice with everyone else, and convince 6 billion Other Guys to change the foundations of their economies.

Of course, this error is not unique to Climate Change changers, but is common among those we know as the Sinceres. While Sinceres are authentic and often motivated to make you and your world a better place, all of their activity only presents, defends, or justifies themselves and their Sincerity. It almost never focuses upon or produces a change anyone can count in those Other Guys who need Sincere help. When you are Sincere, you are also Certain which makes you a double persuasion muggle.

The description of the people and their communication at these UN open discursive spaces provides an excellent illustration of Sincerity in action. It is nothing but irony to behold authentic experts joined together by science and torn apart by persuasion. Even with the Falling Apple in their hands, they cannot resist the persuasion gravity of the Fallen Apple as they fill precious time and space with their Sincerity at the expense of saving the Other Guys from a falling sky.

Read the Rules and pick the violations that seem most relevant, poignant, or destructive. These seem most obvious to me.

All Bad Persuasion Is Sincere.

If You Can’t Succeed, Don’t Try.

It’s about the Other Guy, Stupid.

Persuasion Is Strategic or It Is Not.

Drive with Science, Putt with Poetry.

You Cannot Persuade a Falling Apple.

If You Can’t Count It, You Can’t Change It.

All People Always Resist Significant Change.

Persuaders Can Either Be Famous or Effective, But Not Both.

Great Persuaders Don’t Need Rich Uncles, Kindness from Strangers, or Third Party Vote Splitters.

Past the Rule violations, please catch the lessons with this applied Cool Table. That play is extremely effective with large and diverse groups of Other Guys. You can capture a small number, put them on a Cool Table with rules, enforce those rules, and that Cool Table can produce what you want. They will discover what you already know, form alliances, generate commitment, publicize you and your idea, product, or service, and act as a persuasion agent on your behalf. (And, alternatively, you can use a Cool Table to distract idiots who are in your way. Same principles of operation, just a different persuasion goal.)

Here we see Climate Change changers trying the Cool Table play, but only for their own Sincerity. The absence of control and rules, the vague and nebulous TACTs, and rampant human nature destroy the application, but not the principle. Failure proves the foolishness of the muggle, not the persuasion play.

Schüßler, E., Rüling, C.-C., and Wittneben, B. (2014): On melting summits: The limitations of field-configuring events as catalysts of change in transnational climate policy. Academy of Management Journal, 57, 140-171.

Cut and paste this link to a preprint of the paper as of April 2014.

Journalism Confirms Persuasion Blog Science versus CDC Science

Good grief. I’m dizzy.

Reuters on CDC Obesity Count


Here’s how we looked at that CDC Tooth Fairy Tale nearly three weeks before this article and shortly after the CDC press releases hit the information marketplace.

While the overall population of the study shows no change, you can pick segments of Good News (decrease in kids aged 2-5) and ignore that Bad News (increase in women over 60). And, of course, there are a lot more women over 60 than there are kids between 2 and 5 which further diminishes the cherry-picked finding.

No one predicted directional changes in kids aged 2-5 and women over 60, so this is just navigating by the stars or the asterisks indicating statistical significance within subgroups. Hey, it is Stat 101. When’s there’s no change in the group, there’s no change in the sub-groups either regardless of what the stars say.

The Reuters journalist, Sharon Begley, quotes several experts in her piece, saying pretty much the same thing now that we observed then. Hey! We remain under the radar, panthers, vampires, and werewolves. You are at least minutes, hours, days, weeks, dare I say it, years, ahead of all those pop press FauxItAlls.

Here’s the fun quote from the Reuters article.

A CDC spokeswoman said the lead author of the JAMA study, Cynthia Ogden, “is not doing any media interviews,” but acknowledged that “the sample size is somewhat small so the (ranges of values) are a little wide.”

Of course, that’s not how Ogden put it three weeks ago when she started the CDC Good News Tour that so pleased First Lady Michelle Obama.

“This is the first time we’ve seen any indication of any significant decrease in any group,” said Cynthia Ogden, a researcher for the Centers for Disease Control and Prevention, and the author of the report, which will be published in JAMA, The Journal of the American Medical Association, on Wednesday. “It was exciting.”

Apparently Ogden no longer believes herself. She wisely remains cloistered in her cubicle unavailable for press comment as she works on the next CDC Tooth Fairy Tale.

See the glorious persuasive science. The CDC tells Tales, grabs headlines, and gratifies Mrs. Obama. The press objectively dotes on the Tale and repeats it with no critical stance other than adoration. Where’s anyone speaking truth to power? Then nearly a one month later, another journalist zigs on the zag and grabs some attention for herself. Is America thinning and winning? Is America fat and only that? Who knows? This story gets told both ways. From the same NHANES database!

The CDC has the best available scientific data from the NHANES population surveys and destroys all that value with its self-serving persuasion plays. And the CDC wonders why they have no credibility past the protection of the boss or boss’s wife in the White House.

All Bad Science Is Persuasive.

But, don’t lose the science. The NHANES population survey is the best source of information on the questions it asks and no one walking the planet has better data. No one. You just have to stick to the questions asked and answered with NHANES and not invent Fairy Tales from it.

Hitting the Number with ObamaCare

Pencils down, stop writing (good grief, do people still take tests like that?). Time to count the first change with ObamaCare. According to Fox News (Fox!!!) . . .

On the last day to sign up for ObamaCare, the program apparently was on track to sign up more than 7 million Americans for insurance coverage, though the number of enrollees who have paid for their insurance premiums is still unclear.

A source confirmed to Fox News on Tuesday that the system was on track to see 7 million sign-ups. President Obama, as his team continues to tally sign-ups, plans to deliver a statement in the Rose Garden at 4:15 p.m. ET on the Affordable Care Act.

Even Fox News is reporting that Team Obama will either pass, hit, or come real close to the original public number of 7 million enrollees. That wildly exceeds my prior pessimistic guess, proving once again that I am no prophet of true predictions. Given the disastrous start in October 2013, I’d read the messy tea leaves to see a handicap that could not be overcome. Yet Team Obama managed to rise above that PR and persuasion disaster to hear Fox News declare the change counted out to 7 million or thereabouts.

My prior analysis clearly underestimated the impact of both the quantity and quality of the persuasion campaign both Big Fed and Big Insurance ran. Media sources like the Associated Press estimated that Big Fed alone would spend about $650 million for the effort, but that’s just a guess. To my knowledge, there’s no official number from either the White House or a source like the Government Accounting Office. So, we can only estimate. That’s about 100 dollars per enrollee.

Assuming that guess is close, let’s do some more back of the envelop for the next persuasion budget. We got 6.5 million new enrollees for $650 million of persuasion. We started with 48 million uninsured. If all the new enrollees were previously uninsured, we’ve now got 40 something million to go. At 100 dollars per enrollee that works out to a persuasion budget of $4 billion dollars. And, of course, none of this math includes estimates from Big Insurance.

While I’ve been proven an idiot who cannot count the future change, I’ll persist with as much humility as I can muster, and offer a continuing persuasion analysis.

First, and foremost, a big Hell, Yeah to Team Obama for their dogged drive and creative adjustment. That October Surge was about as bad a persuasion start as you can make and still remain in the game. Team Obama hung tough, focused, adapted, and pushed on.

Second, I’d like to know more about the adaptations in detail. In outline it appears that Team Obama removed key personnel, brought in better talent, and probably simplified the lines of authority and responsibility. Snatching success from this initial failure will be an interesting case study in practical persuasion. From my Fed experience, I will testify that key personnel and a personally engaged President make many things possible. If the guy in the Oval Office is making calls, stalking the hallways, and yanking people by the hair, the system tends to fall in step. This solves many of the vices of committee persuasion.

Third, I have no idea where this goes. The deadline for enrollment is over, so that kind of counting stops, but we’ve still got over 40 million people uninsured. Even if Team Obama got 7 million brand new, formerly uninsured to pay premiums in this persuasion campaign, that leaves nearly six times as many still uninsured. Man, that’s a lot of Other Guys unchanged.

Fourth – and let me underscore that I’m predicting here and we know my track record on that – I think that Team Obama is publicly happy about hitting 7 million enrolled and privately stunned that it’s only 7 million. I think they believed a $650 million persuasion campaign would be the face that launched a thousand ships. Goodness, the goal of ObamaCare is 48 million uninsured in the system. Yeah, we got 7 million, but that’s about 1 out of 7 leaving 6 out of 7 to go. ObamaCare began as your friendly government here to help with a funny President doing the talk show circuit. Now, by law, it converts to your mean government with fines, penalties, and nagging reminders of your failure to comply.

Fifth, if you enjoy doing persuasion, you’ve got to love this challenge. You’ve still got the White House and the Executive Branch at your command and a willing and committed partner in Big Insurance. And while things look tough for the mid term elections of November 2014, remember: You only have to be better than your opponent on Election Day.

This case study with ObamaCare requires thought about Strategy, Tactics, and Operations. Team Obama did a pretty standard national persuasion campaign, very much along the lines of a political campaign. Whether that is the right approach for enacting a law like ObamaCare concerns Strategy. Is getting health insurance like voting? Should you make the implementation of a law something like the opening of a movie? Normally, a law is run as a big Skinner Box with a set of When-Do-Gets that are announced then enforced. Today you pay a tax. Today you drive a speed limit. Today you recycle. Whatever.

That kind of Skinner Box is a very different kind of persuasion than Obama Between the Ferns with Zach.

Decision Aid as Persuasion Play

JAMA Internal Medicine provides a research report on the effect of decision aids on mammogram discussion and usage among women over the age of 75. It is a simple study that exposes complex persuasion. Let’s start simple.

Researchers designed an 11 page decisional aid (pdf Decisional Aid Supplement) with text, charts, graphs, and numbers as rates or percentages. They recruited 45 healthy women over 75 in a clinical setting and asked them to complete a pretest and a posttest about breast cancer and mammography. In between, all 45 women read over the decisional aid, interacted with it as designed, and provided an evaluation of the decisional aid itself (comprehension, bias, usability, and so on). The crucial outcomes measured at pre and posttest were knowledge, intention to get a mammogram, and decisional conflict (how uncertain they felt about the issue). The results.

Participants’ knowledge of the risks and benefits of mammography improved: women answered on average 1 (interquartile range, 0-2) more questions correctly on the 10-item index. After reading the DA, fewer participants intended to be screened . . . Decisional conflict declined after reading the DA but not significantly.

So, the Other Guys got smarter, rejected mammography, and tended to feel more certain about their decision. Here’s the table for the intention to get a mammogram.

DA Screening Intentions

You see clearly that the decisional aid really moved the dial with these 45 women from pre to post. It either decreased intention or increased uncertainty. But, it in no way motivated these women to sign right up for a mammogram.

Interestingly the women perceived the decisional aid as somewhat biased against mammograms.

Forty-two percent (18 of 43) found the information balanced, 42% (18 of 43) found it slanted toward not getting a mammogram, and 16% (7 of 43) found it slanted toward getting a mammogram.

Of course, there are serious weaknesses in this study. Only 45 Other Guys in a convenience sample with a pre-post test! This is a repeated measures t-test design without a control group. Any persuasion panther, much less scientist, who did “message testing” like this would deserve any beating she gets. One sample with 45 people ain’t much to go on. Replication. Vary the contents of the decisional aid. Provide other comparisons (recommendations from the AMA or a US health task force, for examples).

Science aside, now consider the persuasion.

What’s a decisional aid? A decisional aid is medspeak for an interactive sequence of information and questions that guides Other Guys through the known science about a particular medical issue. Here the decisional aid takes Other Guys through breast cancer risks and mammograms.

This aid begins with an orientation about the topic (breast cancer) and headline scientific knowledge in both text and numbers written in a very easy to understand style. The aid then asks a series of health questions (height and weight, recent hospitalizations, diabetes, etc.) about the respondent and she has to write her answer to the question and convert the response into a number written on the right side of the page. At the end of the 10 or so health questions, the woman then totals up her score and sees this.

DA Mammogram Effect Summary

The aid continues with a lot more numerical information very simply designed and reported about risks and outcomes related to breast cancer and mammography. Here’s an example.

DA Numerical Example

An infographic or Pretty Picture, but more scientific than usual. It is an exact visual representation of numbers, specifically, rates. Now, the aid presents one final interactive element. This is the last page in the aid before a question about intention to get a mammogram with completes the 11 page decision aid.

DA Pros and Cons

Each woman takes a moment reflect over the preceding 9 pages of text and numbers then checks off any of the Pro or Con thoughts already printed on the paper. She can also then add her own thoughts in those blank lines.

[ELM/HSM Brownie Point: Yes, that is what you think it is and we will get to it. Now, spin the propeller on your head and fly back into the post.]

From this description you see the sequence of information and interaction. The aid presents data, facts, numbers, conclusions, and so on from the scientific peer review literature. The aid asks the Other Guy to provide personal health information that is then immediately scored for comparison against an easy to understand summary in graphic form. Then more information and that Pros and Cons interaction.

Now, you can call this a decisional aid.

You can also call it push surveying.

You can call it choice architecture from Nudge.

Or you can call it a Biased Central Route persuasion play.

Each label means the same thing: sequenced information and interaction that guides the Other Guy through an issue. In this particular instance, the WATTage is probably quite high for each Other Guy, the information is nothing but Argument, that summary health score manipulates a biased schema, and the Pros and Cons interaction provokes the Long Conversation in the Head (and documents it) that doubtless follows the flow of the Arguments and that biasing treatment with the personal health score.

In this application, the decisional aid persuaded these Other Guys to reject an action they’ve been taught to accept for most of their adult lives. Think about that. These women were at least 75 which means when the big push for mammography began in the late 1970s, these participants were adult women. They’ve heard nothing but Get A Mammogram all the time for 30 or 40 years. Then they go through a decisional aid and reject expert advice, habit, and norm.

And just to reinforce that point, the researchers tracked the health records of these women for six months to see if they discussed mammography with their physicians. Read this interesting comparison.

Fifty-three percent (24 of 45) of participants had a PCP note documenting a discussion of the risks and benefits of screening within 6 months of participating compared with 11% (5 of 45) in the previous 5 years (P < .001).

Before the decisional aid, 11% had every had a noted discussion with their physician about mammography. After the aid, 53% had that discussion. That’s a near Large Windowpane increase. The actual screening rate also decreased from 83% before the aid to 60% in the year following – a Small+ Windowpane. Thus, you see changes in future behavior from this decisional aid. And, all those behavioral changes go against that 30 or 40 year history.

The persuasion point is not that this decisional aid is good or bad, but rather that is captures basic persuasion principles. If you changed the information from one cited study in decisional aid to a different source, you could change the slant of the decisional aid in a different direction. You could manipulate the scoring on that personal health questioning to either increase or decrease the score as with push surveying. You could drop either the Pro or the Con thought listing and increase the biased processing.

This thing works as persuasion because it puts Other Guys on the Central Route.

A research assistant (M.C.G.) administered the pretest survey. We then asked women to come to a routine appointment with their PCP early to read the DA. After reading the DA, which takes approximately 5 to 10 minutes, participants attended their scheduled visit.

You take each Other Guy one at a time, a research assistant meets the woman, takes her to a separate room, explains the procedure and then gives the woman the decisional aid. I’d argue that this is likely to produce a thoughtful high WATT consideration of the decisional aid.

With receivers who are so tuned in, the aid then provides Arguments, information that bears on the crucial merits of cancer and testing. It further encourages more thinking about those Arguments with that summary health score, but with a bias. If your score is low, the that graphic arrow tells you that you need a mammogram while if it is higher, you don’t. Consider that these are people over 75 those health scores will not be 0 or 1 or 2, but rather higher and the inevitable biasing conclusion provided in the graphic that mammograms aren’t helpful. Finally, the aid locks in that biased conclusion with that Pros and Cons task with drives the Long Conversation in the Head. Technically, this is called a “thought listing” and is used to measure elaboration activity in research. Here, it is a persuasion play.

Of course, among these researchers this thing is just a neutral, objective, and scientific presentation. Dispassionate. No one is telling you what to do. Think for yourself.

And, of course, this is nothing but persuasion. Change the contents of the information to other “scientific” sources, change the slant of the infographics or that health score or the thought listing task and I guarantee you will get different persuasion outcomes. Which one is the real science?

When you are thinking and doing what a medical researcher thinks you should think and do, it’s decision making. When you look at it with the cold heart of a panther, baby, it’s only persuasion. Everything about the design of a decisional aid shrieks with persuasion and manipulation.

Any decisional aid relies exclusively upon what the designers believe is the proper sequence of information and questioning. If you happen to have a large financial stake in the outcome of a decisional aid, the aid will look different compared to a decisional aid created by an NIH task force given a set of predetermined rules for evaluation. As we’ve noted before, Big Pharma runs “decisional aids” in the form of push surveys that have that sequence of information and questions that subtly guides the Other Guys to a desired decision. Also, a notable form of the Nudge, the thing called choice architecture, is a decisional aid that sequences information and questioning.

The really fun part of this play is how it gets hidden in the label, decisional aid. Call it that and you are scientific. Call it, instead, a push survey or a Nudge or a biased Central Route play and you are both scientific and persuasive.

As a practical persuasion play, consider a decisional aid. Give the thing to Other Guys in a physical setting that looks thoughtful, scientific, technical like a doctor’s office, but for your specific Local. Have a research assistant administer the decisional aid and make sure he or she is dressed to look smart, objective, but friendly. You must build an Authority Box for the Other Guy.

Now, design a decision aid with as much simple science as your TACT possesses. Don’t do any fancy Pretty Pictures like Tooth Fairies or fMRI pixies. Essentially use graphics instead of numbers to express exactly the quantity. Provide citations and references whether to the New England Journal of Medicine or the New York Times or the New New Thing. Include some kind of self report that the Other Guys score and count for themselves, then provide that biasing summary graphic that pushes the Other Guy to the high or low side as you wish. You can manipulate that three ways.

1. The specific questions you ask.
2. The score values you provide for each answer.
3. The label range of Low versus High on the summary graphic.

In this example, the self report of health status asked questions that were guaranteed to get “more” or “higher” responses that were then cut to count higher. The summary graphic at the bottom also provided less space for the “low” side of the graphic and more space for the “high” side of the graphic. By design, most women had to score “high” on this play which required them to count the change against mammography.

Finally, run everyone through that thought-listing play with Pros and Cons. You could further bias this by including, for example, Pro statements that no one would think and Con statements that everyone thinks, thus pushing a negative Long Conversation in the Head. Or reverse it and provide Pro statements that everyone thinks and no Con statements and get a positive Long Conversation in the Head.

You see the amount of effort this persuasion play requires, but remember, you’re pushing the Other Guys on the Central Route and that requires effort from both you and the Other Guys (although you have to hide your effort so the Other Guys doesn’t make an External Attribution to it). You expend effort on building the Authority Box, but you make it look natural, easy, and normal. Then that decision aid encourages High WATT processing with the biasing plays built into it.

The payoff from all this effort is not just with immediate change from the Other Guys, but their persistence, resistance, and future action. Central Route change is strong and elicits an internal structural change in beliefs and attitudes that the Other Guys maintain when they leave the Authority Box. They are now operating under their own steam. With Cue-based change on the Peripheral Route, you’ve lost the change as soon as they leave the scene and you have to hit them again with another Cue the next time. With this biased Central Route decision aid play, you work hard once.

This turned in ways you probably did not expect. Hey, this is the science of cancer and testing, right? What could be more scientific than a scientific presentation of the science? The researchers themselves display a blissful ignorance of the persuasion filling their sails and think this is the real Dr. Doctor MD.

But since we’re beyond good and evil here and beyond the perimeter with persuasion, we can see more widely. Properly constructed and executed, a decision aid in an Authority Box is a killer persuasion play.

Schonberg MA, Hamel M, Davis RB, et al. Development and Evaluation of a Decision Aid on Mammography Screening for Women 75 Years and Older. JAMA Intern Med. 2014;174(3):417-424.


P.S. So. Is there any science here? Well, you can still find guys in White Lab Coats who will testify like a prophet in the desert about Screening Now, Screening Tomorrow, Screening Forever. And they publish in JAMA, too.

My read of the research literature is that unless you have some kind of diagnosed problem, screening as a population tool (Screening Now Tomorrow and Forever), is almost always useless and dangerous; healthy people will get killed from the “false positive” and the unhealthy will survive based on treatment quality and not the screening. Catch It Early is pretty much a persuasion meme and not a well demonstrated piece of science.

P.P.S. And even with the nice graphical presentation of numbers, we know that whether you use numbers or icons, people still don’t understand the thing better. Remember this experiment? Smart people think you can explain complex ideas with simple pictures and you can’t. I’d argue again that the effect of this decisional aid is persuasive, not informational.