Alive! An effective diet and physical activity behavior change intervention via email
Project Street Address
Project City
Project Province/State
Project Postal/Zip Code
Project Country
Focus of activity
Technology
Year the initiative began (yyyy)
2006
Which of these barriers is the primary focus of your work?
Health care not consumer friendly
Which of the principles is the primary focus of your work?
Simplify through technology
If you believe some other barrier or principle should be included in the mosaic, please describe it and how it would affect the positioning of your initiative in the mosaic:
This field has not been completed
Name Your Project
Describe Your Idea
Define the innovation
One glaring failure in our health care system is the absence of scientifically-based widely accessible nutrition and activity screening, accompanied by an affordable intervention. Alive is a screening and behavior-change intervention system, individually-tailored, that comes directly to the consumer through email. It has been proven to improve physical activity, fruit/vegetable intake, and saturated and trans fat. It will benefit the >50% of the population who get too little physical activity, too much saturated and trans fat and sugar and too few fruits and vegetables. All are associated with numerous chronic diseases. Alive makes a personally relevant behavior change program accessible, because it comes to the user’s home or workplace via email and does not require trips to a health center, or the availability of a dietitian. The cost is far less than any intervention requiring health care personnel, inexpensive enough that organizations could afford to offer it to their employees or members. Yet, it incorporates proven principles from educational and behavioral psychology, such as tailoring to individual characteristics, goal-setting, and others. Users complete a questionnaire, and instantly get feedback on where their diet and activity needs improvement. Weekly emails contain individually-tailored goals to act on for the following week, health information, and interactive tools. The goals are tailored to each participant’s characteristics: whether they have kids at home, eat out a lot, do the cooking, preferred kind of exercise, current physical activity level, and their own food choices. Alive differs from existing websites, because Alive pushes the intervention messages rather than passively waiting for users to seek it out; and from emailing systems because its messages are much more extensively tailored to the individual, rather than generic information and tips. And unlike other online services, it has been proven effective in a large randomized trial.
Context for Disruption:
Although the need for physical activity and dietary behavior change is enormous, the solutions have been expensive, largely ineffective, and unavailable to most Americans. Alive makes near-universal screening and intervention possible cost-effectively, conveniently, and effectively. Inactivity and dietary factors are associated with numerous health outcomes, including obesity, diabetes, heart disease and cancer. In response, governments mount social marketing campaigns, which have increased awareness but produced little behavior change. Doctors advise patients to exercise and eat better, but their available time is far too limited and they have few tools for screening. Patients with diabetes or severe obesity may be referred to a dietitian, but this is expensive and rarely available as preventive care. Classes are offered as a preventive service, but these are expensive, require trips to a health center or the availability of a dietitian, and few attend or persist. Large companies have instituted preventive services, but most smaller companies cannot afford to do so. Thus, despite such efforts, the great majority of Americans do not meet dietary and physical activity guidelines. With increased awareness, most people know in general that they should eat better and be more physically active, but they receive no effective assistance to do so. With Alive, screening is universally available, showing exactly where change is needed for each individual; and it is followed by a proven behavior-change intervention. It can be delivered to anyone with email access, conveniently at home or workplace. It employs proven behavior change principles. It is inexpensive. And it has been proven effective. In the short term, Alive has significantly improved behaviors in one worksite. In the long term, these methodologies can change health care and industry practice, making effective screening and preventive services almost universally available and complementing other efforts.
Delivery Model
Alive is delivered to the end user by email. The invitational email is sent by an organization to its entire email list. Since Alive has been tested in a worksite population, one initial target market is medium-sized and small businesses. While many large businesses may already have prevention programs in place, many smaller businesses would like to provide such services to their employees, if the costs fit their budgets. The program is being offered to businesses and organizations through a licensing structure, with charges based on the number of employees. The program runs from our web/mail server, with secure confidential locations for each organizational client. There is minimal or no requirement for personnel time or expertise by the client organization. A second delivery model is through online social networking sites. We have completed the programming and in late July will launch Alive as an application on Facebook. In this case the target population is individual consumers. The initial screening questionnaire and instant feedback will be available free to all. After receiving the feedback, those who wish to participate in the 12-week program will pay only $10. With 30 million Facebook members, and the viral nature of these communities, we could make a contribution to public health and also generate considerable revenue from this channel. We as yet have no paid market penetration in the business or organization market. Our randomized trial ended only a short time ago, and we have not yet published or begun advertising. However, Alive is being made available free to employees of a large health organization and to faculty and staff at a university, with excellent response. In addition, we presented Alive at a large health promotion conference, with extremely enthusiastic response. At least 30 people asked questions or came up afterwards to discuss it. This and other word of mouth has generated approximately 15 serious inquiries, with discussions ongoing.
Key Operational Partnerships
Our current key partnership is with Kaiser Permanente of Northern California. Through their Division of Research we developed and tested Alive in a randomized trial. Staff in the Employee Wellness division are currently discussing using Alive for the entire northern California employee roster. In addition, we have applied for a grant from CDC, in which Alive would be offered to northern California Kaiser health care personnel. Finally, we propose to begin discussions with Kaiser about potential uses of Alive for their northern California membership. Should either the use in Kaiser employees or in Kaiser membership become a reality, it would be a steppingstone to use in other Kaiser locations throughout the nation. Our second partner is the University of California at Berkeley. We offered it free to faculty and staff as part of an employee wellness initiative by the Office of the President. It was well received, and we will offer it again this Fall. We have received an inquiry from another University of California campus. Since Alive now has demonstrated proof of effectiveness, the support of employee wellness staff at Berkeley, and interest from other campuses, we propose to approach the Office of the President to discuss the use of Alive on all University campuses, through University wellness funding. Through grant funding, we have formed relationships with California’s Div of Cancer Control and, less directly, with the CDC. These have been crucial to our initiative.
Financial Model
Our financial model involves covering the operating costs of Alive from license fees from employers/organizations in the organizational delivery model, and from subscription fees from individual users in the social networking delivery model. It is our intention that, ultimately, fees for Alive will entirely cover operating costs, and that profit from this source will ensure its sustainability. We are a for-profit company, and have been in business since 1994. At the moment, Alive is being provided free to several organizations. We currently have no paying clients for Alive, and our current operating costs are being covered from proceeds from our core business, and from our subcontract on a CDC grant. The amount listed below for annual operating budget is an estimate of current expenditures on Alive for modest maintenance programming and management. To begin to reach our target business/organizational markets will require expansion. We can cover this to a very modest extent from self-funding, and (hopefully) receive some assistance from grants. However, to greatly expand the reach of Alive, to the point where millions are receiving our weekly behavior-change support, will require a substantial increase in outreach, marketing, sales staff and specialized expertise.
What is your annual operating budget?
$160,000
What are your current sources of revenue? (please list any sources that are foundation grants)
1.) Clients of our core business (nutrition and physical activity analyses for health research) 2.) R & D contract for development of the Alive Program (sub-contract of CDC grant)
Effectiveness
Alive has been tested in a randomized controlled trial among Northern California Kaiser Permanente Regional employees; 797 employees participated in the trial. Even with a strict analysis in which persons who do not return the follow-up questionnaire are assigned a change score of zero, we found statistically significant increases in total physical activity, moderate physical activity, walking, total MET-minutes, and fruits and vegetable consumption, and statistically significant decreases in saturated and trans fat consumption. We also found significant improvements in self-reported overall health status and quality of life (SF-8 Physical), and significant decreases in “presenteeism” (workers present, but functioning below par for physical and mental health reasons). As a result of this trial’s results, as well as enthusiastic endorsements from users, the Kaiser employee wellness representative is extremely interested in using Alive for all Kaiser employees. Discussions are just beginning. In addition, Alive was offered to faculty and staff of the University of California at Berkeley. Approximately 200 participated, and the response has been so positive that the University Health Services wants to offer it again this coming year, with enhanced promotion. Thus, after brief exposures for their employees, two large organizations are seriously considering using Alive. Such organizations have previously offered courses that employees could attend, or gyms where employees could exercise free or at reduced costs. The proportion of employees who actually made use of such opportunities is unknown but probably low. If Alive is offered at these organizations, the result will be easily-accessible behavior-change support for potentially very large proportions of their employee populations. To see an example of an Alive email and personal web page: http://www.nutritionquest.com/aliveExamples/
Which element of the program proved itself most effective?
Feedback from the randomized trial showed that participants felt that the continual support through repeated interaction and reminders was very important. We also believe that the tailoring of the suggested goals to the participant’s own behaviors, preferences and practical constraints of daily life was critical, as was the fact that Alive offers explicit, small-step, achievable actions that people can take to move themselves in the right direction. In addition, users expressed enthusiasm for the “What if…” tool. This unique interactive component of Alive enables the participant to simulate the effect of making specific changes to their diet or physical activity. For example, “What if I ate hamburgers one day a week instead of five days a week?” The program recalculates their total saturated fat score, moving a slider closer to the “Desirable” score. This easy-to-use sliderule type approach enabled individuals to experiment with different ways to modify their own diets or exercise programs, and resulted in the ability to take control of their own behaviors by modifying foods and activities which they themselves selected and preferred. In terms of effectiveness for client organizations such as employers, we suspect that the following will be considered important: its very low cost; the fact that it takes little or no time and expertise on the part of the organization; and the fact that it has been proven in a randomized controlled trial to improve the health behaviors and well-being of employees. It is also notable that Alive’s screeners represent health risk assessments for important dietary factors (saturated and trans fats, sugars, fruits and vegetables) and physical activity. Everyone, regardless of whether they sign up for the 12-week program, receives the assessment and individualized analysis. And for those who do sign up, Alive follows the health risk assessment with a proven intervention.
Number of clients in the last year?
The Alive program, a brand-new product, has just completed development and testing. Its randomized, controlled trial in a worksite population reached 797 employees. Its use in University of California/Berkeley faculty and staff has thus far enrolled 200 people. Marketing is just beginning. In our core business, our company served approximately 100 organizational clients last year, primarily university-based health research groups. These researchers used our highly regarded services in developing and analyzing nutrition and physical activity assessments, printed and on-line. Those services permit researchers to carry out clinical investigations of the relation of these behaviors to health. NASA, another client, uses our analyses to monitor the nutritional intake of all Space Station astronauts. The dietary screeners and analyses used in Alive are adaptations of these widely used dietary screeners. This aspect of our business, diet and physical activity screeners and longer assessments, represents another potential contribution to public health that has not been fully exploited. Our assessment instruments, initially for researchers, have evolved to be adaptable to the needs of brief clinic visit or individual screening. Every medical encounter could include a 5-minute screener, a trigger for automated feedback and a few words from the doctor. This could be followed if needed by a longer assessment and for those needing intervention, either referral to a dietitian or assignment to the Alive program. Validated screeners and longer assessment tools can be accessed in online, offline, or mail-in form. We believe that with our development of Alive, we have provided the components for a full screening-assessment-intervention triage system.
What is the potential demand?
The demand for Alive will come from those seeking to improve their diet and physical activity habits, specifically those who use the Internet at work or at home. In some cases that demand will be expressed by individuals and in other cases by employers, insurers or HMOs. Overall, demand potentially constitutes a majority of the US population. In 2006, 74% of Americans had Internet access at home and more at their worksites. During April 2006, 152 million Americans used the Internet. Health-related topics are among the most popular. The Pew Internet and American Life Project reports that “Eight in ten internet users have looked for health information online, with increased interest in diet, fitness….” The context is right for a service that will support people in improving their diets and increasing their physical activity. The media have daily stories about the need for Americans to increase their physical activity and the virtues of a better diet in preventing chronic diseases such as cancer and diabetes. We believe most people already want to change their behavior, but many need practical advice and sustained coaching in order to do so. Meeting that demand is what Alive offers, at a very low cost and with great convenience. In addition to individuals seeking to improve their health, employers are rapidly increasing their demand for “wellness” programs, to reduce absenteeism and “presenteeism”. Encouragement for employer-provided wellness services is coming from many sources, including the CDC, the National Institutes of Health, foundations, employer groups, and health insurance companies. Alive is one of the few programs with scientific evidence proving that it results in significant improvements in workers’ physical activity and dietary intake, through a randomized controlled trial funded by the CDC. It is low cost, very easily administered by any company, and effective. We thus believe that demand for it will be substantial.
Scaling up Strategy
We are focusing on three types of client: organizations who may offer employee wellness programs; individuals; and HMOs. Our three year strategy and projections of potential numbers reached follow. 1. Organizations. We will market to small and medium-size businesses, which typically cannot provide costly, comprehensive on-site wellness programs. Small businesses (500 or under) employ 51% of the US workforce (58.5 M) and medium-size companies (500 to 1000 employees) another 5%, for a total of 64.6 million workers. We estimate 2/3 have Internet access at work, yielding a potential market of almost 43 million from this source. Our target is 5% company enrollment, or about 2.15 million people. We will employ a marketing/sales executive to lead the effort and plan to be advised by “key informants” such as company wellness directors and wellness brokers. 2. Individuals, through social networking sites. The Facebook application described earlier will be immediately available to 30 million people, with more to come. Facebook’s membership has recently skewed to a majority over age 24, with 40% over age 35. Conservatively, then (omitting teenagers) there are now 25 million potential customers. Our near-term target is to enroll 1% of that population during Alive’s initial launch, or 250,000 people. 3. HMOs providing wellness and disease prevention programs for their enrollees. HMOs enroll 158 million people. Essentially all provide some wellness support through web pages, as well as through in-person classes and other inter-personal means. We plan to ask these HMOs to provide Alive as a Plan-funded service or as a low-cost subscriber option. 74% of the US population has Internet access at home. We thus estimate a potential HMO audience for Alive of over 117 million. If 5% were to participate, Alive would reach 5.9 million. Taken collectively, the near-term health impact of Alive thus could benefit over 8 million people, and potentially several multiples of that.
Stage of the initiative:
1
Expansion plan:
We have two expansion strategies: development of related products and expansion within already-defined markets. We have designed Alive to permit us to readily adapt the system to target health outcomes of importance to other potential client groups. Our hope is to do so for pre-diabetics, older workers, and retirees. Funding will be needed, for partnering with experts on these populations, for programming, pre-testing and then targeted marketing. Our small and medium business market is very large but also very disaggregated—5 million small businesses and 8,400 of medium size. While we can reach a limited number of such firms with the marketing capacity we will be adding this year (one senior professional and a modest budget), a serious expansion will require the funds (and knowledge) to hire and support experts in marketing wellness products to these types of organizations. Our hope is that early product sales will permit self-funding for initial efforts. However, if we do not grow our market share quickly, competing services from larger companies are likely to pose a serious threat. Even though they are unlikely to have the scientific evidence for effectiveness that we have obtained, their greater marketing muscle could win the day, to our detriment. Similarly, we expect to need specialized expertise in marketing to HMOs. As an established small company with a long profit-making history, and a demonstrated product, we may be attractive for financing support.
Origin of the Initiative
Dr. Gladys Block, co-owner (and Prof at UC Berkeley) is a pioneer in demonstrating the health impact of fruit and vegetable intake, through research at the National Cancer Institute. The national 5-A-Day social marketing program resulted from her research and advice. She has also been instrumental in developing dietary and physical activity assessment methods based on national consumption data. Add to this set of skills Dr. Clifford Block, a behavioral psychologist with long experience in large scale health behavior change campaigns. We saw the opportunity, with technology, for personally targeted advice based on assessments and proven behavioral principles. A grant from the State of California funded initial development and a successful pilot trial in a workplace (the WIN program). This led to partnership with Kaiser to add physical activity and to test Alive in a randomized trial.
Issue Selector
What are your two main challenges to finance the growth of your initiative
Our two main challenges are knowledge/expertise and personnel. Knowledge/expertise: We know little about financing options or how to obtain them. We have been assuming we would self-finance and gradually expand into the market. Realistically, this won’t get us to where we need to go fast enough. Exhaustion and larger more aggressive companies will overtake us before we have reached 5% of the potential market of Alive. So we need real guidance on what we should do. Personnel: With self-financing, acquiring personnel will be very limited. We need marketing expertise in each of several areas. (E.g., how do you reach HMOs?) We need a sales force. And, because we are a very small business, with staff already stretched to the limit, we need a manager to manage the expansion of Alive. We need consultants in the areas we want to expand into, and personnel to actually develop content for new areas (e.g., nutrition guidance in prediabetics). And of course, we need high-level computer programmers to manage and expand our very sophisticated application. Just to scale up appropriately in Year 1 would require over $1,000,000 (see below).
How did you hear about this contest and what is your main incentive to participate?
We heard about it through a listserv of Robert Wood Johnson Foundation. Our motivation is to make the health community aware of Alive (which we are very proud of), and to attract advisors and funders.
Do you have an annual financial statement?
Yes, since becoming an S-Corporation in 2005.
Do you currently have an annual financial statement that tracks profit/loss?
Yes, since becoming an S-Corporation in 2005.
Please describe the amount (and/or type) of funding you need to implement your initiative, at year 1 and at year 5.
Year 1, scaling up: Personnel: Alive Project Manager: $100,000 Alive-dedicated programmers: (2) @ $175,000 Marketer: $80,000 Sales persons: 2 @ $60,000 Content developer: $60,000 Office Manager/assistant: $45,000 Benefits @ 20%: 151,000 Other: Marketing budget: $150,000 Equipment, servers, facilities: $50,000 Rent: @2100/mo: $25,200 TOTAL YEAR 1: $1,131,200 Year 5: By Year 5, we expect that Alive will be profitable and therefore self-sustaining, permitting both self-financing and, if needed, access to additional capital. Our target is to have income of $5 million in five years time from Alive and its adaptations. In addition to planned adaptations to other health conditions, we also expect to adapt to new delivery systems such as personal communications devices.
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