Models and strategies for behavior change (2023)

Last updated: July 1, 2014

Behaviour, the product of individual or collective action, is a critical determinant of human health. Lifestyle-related risk factors are now considered to be the main causes of morbidity and mortality in Europe. The most common chronic diseases in Europe, including cancer, cardiovascular disease, obstructive pulmonary disease and diabetes, are closely related to lifestyle.¹Smoking, lack of exercise, high calorie intake and excessive alcohol consumption leading to obesity, high cholesterol and high blood pressure are precursors to these diseases.¹There is compelling evidence that a healthy lifestyle, including regular exercise, a balanced diet, blood pressure control and not smoking, is associated with longer, healthier life expectancy.¹

However, the behaviors that can cause these diseases are common, and changing them can mean changing old habits. Many people are involved in supporting and encouraging other people's behavior change, and of course many try to change their own behavior and may seek support from others in doing so. Therefore, it is important to identify effective approaches and strategies that encourage change and maintain newly adopted healthy behaviors.²

This overview presents approaches to behavior change and highlights the evidence for their effectiveness. It relates to the development of theories about the processes that shape behavior, empirical studies that test those theories, and applied research. The latter specifically relates to how behavior can be changed in everyday contexts and situations.

1. An ecological approach to behavior change

There are a variety of personal, social, and environmental factors that influence behavior. Most can be assigned to three levels:³

• Personal or individual: beliefs, knowledge, attitudes, skills, genetics
• Social: Interacting with others, including friends, family, and community.
• Environment: the area in which a person lives, e.g. School, workplace, local shops and amenities, and more general factors such as economics (like prices) and technology.

A complex web of social and biological factors must be considered in attempting to combat obesity-related behaviors.⁴Behavior change is usually best achieved through a combination of interventions, implemented over a long period of time and modified in response to measured impacts. Interventions that only address factors at the individual level and do not address the above social and environmental influences are unlikely to work. An ecological approach "that identifies and addresses factors that influence behavior at all three levels is probably the most effective way to achieve behavior change."³This approach also appears to be the most cost-effective.⁵

2. Information and advice are not enough

The traditional approach, still sometimes used in health advice and media campaigns, is based on providing advice and information directly. While information is important to educate and inform consumers, it is rarely enough to change behavior. It is based on the assumption that people lack knowledge (what they should be doing) and that increasing knowledge changes attitudes and creates a desire for change.⁶It does not take into account the many complex influences on behavior. This approach prescribes changes to the client in a style that can be perceived as being told what to do. Healthcare professionals may emphasize the benefits of the change without fully addressing the personal implications for the individual, which can lead to resistance to the change.⁷The same is true of many educational programs and awareness-raising campaigns. Providing information will likely appeal to those who want to know how to change their behavior. The information provision approach, in turn, can exacerbate health inequalities and penalize those whose behavior is directly influenced by their environment and who may have less access to or desire for information.⁸

Theories and models of behavior change

In recent years there has been a great deal of interest in behavioral theories and models of behavior change, much of which derives from psychology and is shaped by economics and sociology.⁹They take into account the wide range of psychological, social, social and contextual factors such as emotions, habits and routines.¹⁰Intervention theories to support change describe how behaviors evolve and change over time. Behavioral models are designed to help us understand behavior and identify the underlying factors that influence it. An understanding of both aspects is necessary to develop effective intervention strategies.¹¹

More than 60 social psychological models and behavioral theories have been identified, many of which have been used as the basis for the design and implementation of health promotion programs with varying degrees of success.¹¹There is strong evidence that the use of theory in the design and implementation of behavior change interventions improves the effectiveness of the interventions.^2,12However, published studies often lack the details of the applied theory. As recently reviewed, only 44% of 34 randomized clinical trials in adults with obesity reported the theoretical basis for behavioral interventions.¹³The most widely used were the transtheoretical model and social-cognitive theory (see below), although a third of the studies reviewed did not explain why a particular theory was used. The theory of planned behavior has also been successfully applied to physical activity and nutritional interventions.^14,15

• Transtheoretical model (also known as the "stages of change" model): Segments the audience and tailors the intervention to the stage of change: preview, contemplation, preparation, action, maintenance, and termination.
• Social Cognitive Theory: Focuses on the role of observing and learning from others and the positive and negative reinforcement of behavior.
• Planned Behavior Theory: Assumes that people's behavior is determined by intention and by attitudes, subjective norms (beliefs about whether other people agree or disagree), and perceived behavioral control (beliefs about whether it is easy or difficult to do so). do) is predicted.

Models and theories identify behavior change techniques. Interventions often use several different behavior change techniques.^sixteenThey range from providing information (e.g. about behavioral consequences) to setting concrete goals and opportunities for social comparison. They may also include stress management, motivational interviewing, and time management.¹⁷

3. Which behavior change techniques are most effective?

It is not entirely clear which techniques are effective under which conditions. Self-control and other self-regulation techniques (goal setting, cues, self-control, performance feedback, goal review) are consistently described as effective tools for behavior change.^18-20Medium- to low-quality evidence suggests that dietary change is best supported by:

• Provision of teaching (teaching behavior),
• Self-monitoring (behavioural recording, e.g. keeping a food diary) and
• Relapse prevention (problem solving and identification of coping strategies),

while physical activity is better supported by:

• Alert (to stimulate behavior e.g. phone reminder),
• Self-monitoring (recording of behavior, e.g. keeping an activity diary),
• personalized communications (adapted to the change phase, resources and context),
• Set goals (e.g. step goals monitored with a pedometer).¹⁸

Diet and exercise interventions appear to be more effective in weight control when addressed simultaneously.¹⁸There is also good evidence to encourage the involvement of social support (usually from family members).¹⁸

Sustaining behavioral change over the long term is a challenge. There is evidence that time management techniques (e.g., how to fit activities into a daily or weekly schedule) can help maintain physical activity levels. Encouraging self-talk (ie, talking to yourself before and during planned behaviors) is another useful technique to facilitate physical activity and healthy eating.¹⁸

self-determination theory

The combination of skill development with underlying, intrinsic motivation and reason is considered essential for lasting change. Intrinsic motivation does not depend on external pressures, such as B. Rewards/approval or punishment/disapproval from peers or healthcare professionals. It exists within the individual and is driven by interest or pleasure in the task itself. This is the basis of the self-determination theory. Unlike rewards and incentives, self-directed motivation is believed to be stable and long-lasting.^21,22The individual must believe that the behavior is comfortable or consistent with their “sense of self”, values, and life goals. This is supported by examining why someone should persist or how the new behavior relates to larger goals.²²People need to have a sense of agency and responsibility for their actions, feel empowered to achieve the goal, and also be understood, cared for, and valued by others.

The Self-Determination Theory was the basis of a year-long weight control program that enrolled approximately 250 overweight or obese individuals. The program used self-regulation techniques and education about energy balance and body image. Participants were given opportunities to reduce energy intake and increase energy expenditure. They were encouraged to experiment with different activities to find ones they enjoyed. At the end of the study, the autonomous motivation for physical activity was higher in the intervention group. Physical activity increased in the second year and weight control in the third year. In addition, women who received the intervention reported nearly 90 minutes more moderate-to-vigorous physical activity per week than the control group at year three. The intervention was also reported to positively affect eating behavior.²³

There are many parallels between self-determination theory and motivational interviewing.²³

motivational talk

Motivational interviewing is a counseling approach that uses a combination of behavior change techniques and has been shown to be significantly more effective than traditional counseling. It is a client-centered leadership method to increase intrinsic motivation through exploring and resolving ambivalences and barriers to behavior change.²⁴This approach sees lectures or confrontations as useless. The basic principles underlying motivational interviewing are:⁸

• Expressing empathy (through reflective listening)
• Develop a gap (between the person's goals and current behavior). Avoid arguments
• Roll with resistance (recognize and capitalize on individuals' resistance to change rather than resisting it)
• support self-efficacy

To gain a better understanding of the factors affecting your success, further research combining motivational interviewing with self-determination theory is recommended.²⁵

Motivational interviewing is particularly effective when combined withCognitive Behavioral Therapy (CBT).²⁵CBT is a treatment for emotional and behavioral problems that aims to help people identify and change dysfunctional thoughts, assumptions, and behavioral patterns. Examines the range of factors that influence a person's behavior, both external (e.g., environmental stimuli and reinforcers) and internal (e.g., thoughts). CBT also uses various techniques such as B. Goal setting and self-control, and is based on the belief that all behavior can be learned and unlearned. The systematic literature research by Spahn et al. suggests that using an intensive CBT course (6 to 12 months) may help prevent and delay the onset of type 2 diabetes and high blood pressure. The potential of this intervention has also been demonstrated in the treatment of childhood obesity (30% reduction in overweight versus 9% reduction without CBT).²⁶

It is remarkable that these counseling approaches depend on the self-regulation of the individual.^22,25

4. The role of social marketing

Social marketing is based on some principles of commercial marketing and uses behavior change theory to influence behavior for "social good".²⁷The benefit is to society, not to the organization doing the marketing. The corresponding segmentation of the market enables targeted intervention.

A key example of a social marketing campaign is Change4life, launched in the UK in 2009.²⁸He engaged government, media, industry and retailers to create a social movement to promote healthier behaviors by making new behaviors fun and achievable. Ongoing support was provided to the families through publications and online social media (e.g. Facebook). In addition, 200,000 vulnerable families received support packages, and 44,833 of those families are still involved six months later. More than a million mothers who joined the campaign said they had changed their children's behavior.²⁹Another analysis (cluster randomized control study) of the Change4Life campaign found that while the campaign materials raised awareness of the campaign, they had little impact on the attitudes or behavior of study participants.³⁰It concluded that child obesity campaigns should be more targeted to a narrower spectrum of behaviors and groups of people, using behavior change theory, and using formal pilot testing.³⁰

Social marketing as a behavior change approach has been criticized for its difficulty in promoting the immediate benefits of healthy living. Behavior (e.g. physical activity) is not the same as a product (e.g. running shoes) and in social marketing a consumable is not exchanged between a producer and a consumer. Therefore, social marketing interventions should not be viewed as the sole means of behavior change.³¹

5. Press

An approach commonly known as 'nudge', stemming primarily from behavioral economics, has attracted interest in recent years.³²The goal is to "nudge" people's choices, not by eliminating the less healthy ones, but by facilitating the healthier option. Making salad a standard side dish or making the stairs more attractive than taking the elevator are just a few examples. A person can also be "nudged" by being educated about social norms by receiving feedback on their behavior relative to other people.

Another example is the reformulation of products when recipes are changed to improve their nutritional value.³³This approach has proven effective in reducing salt intake. Governments could also consider tax policies that attempt to influence food prices "in a way that promotes healthy eating." However, policies can be perceived as a 'nudge' rather than a nudge when people are pressured to act against their will.

Not surprisingly, there has been much debate about how ethical it is to push people in ways they don't realize and whether it's effective.³⁴A recent and influential UK report concluded that nudging should be combined with other types of interventions.³⁵

6. Using Technology to Modify Behavior

The age of technology expands the possibilities for behavior change. Electronic health interventions conducted over the internet are becoming more common. They are often cited as profitable, but data to judge this is lacking. The most effective Internet-based behavior change interventions appear to be more theory-based (specifically, planned behavior theory) and use a variety of techniques. The use of additional communication channels, in particular SMS (Short Message Service) or text messages to send motivational messages, e.g. Reminders of the benefits of exercise, facilitating behavior changes.¹⁵For example, one weight loss intervention study was found to be most effective for people who also received 2-5 personalized text messages per day containing advice and questions on various topics (and a monthly call from a trained health coach).³⁶They lost more weight (1.97 kg) than the group that only received printed weight management materials.

Cell phones are good candidates for behavioral interventions. The advancement of mobile technology with embedded sensors for user location, movement, emotion and social engagement increases the possibility of continuous, automated tracking of health-related behaviors. This supports self-regulation techniques (e.g. goal setting and tracking). Such interventions may be cheaper, more convenient, or less stigmatizing (due to private involvement). Additionally, connectivity enables behavioral and health data to be shared between healthcare professionals or colleagues, which can facilitate behavior change. The development and interest in smartphone apps is growing rapidly, but research to evaluate them is still immature. The challenge will be to sustain long-term use and effective behavior change.³⁷

Video games are another platform that attracts audiences. This fun and interactive technology has shown that it can positively influence health-related behavior.³⁸For example, one small study found that combining stationary cycling with interactive video games increased frequency and improved health-related fitness compared to traditional cycling training.³⁹Another study showed higher frequency listening to music, a more cost-effective option.⁴⁰Controlled (laboratory) studies show that "active video games" (which encourage physical interactivity through body movements) lead to mild to moderate physical activity, but few show significant increases.⁴¹Video games are also an attractive platform to change eating habits, especially for children. Research is still in its early stages to understand how these games were designed for maximum impact.⁴²

An innovative approach to individual counseling is telephone counseling, which can provide access to remote clients. Canada has dedicated telemedicine nutrition services with limited reviews (Dial-A-Dietitian, EatRight Ontario). Initial evaluations suggest that this approach shows promise, although more evidence is needed before standards and guidelines for practice can be developed.⁴³

Researchers are beginning to study how online technologies can be made more effective.⁴⁴Due to their high reach and low costs, they promise broad access.⁴⁵

7. The theory of behavior in practice

Many frameworks aim to encourage and support the integration of behavior change theory into the design of interventions. An example of such a structure is shown in the table below.

Different impacts in different population groups must be considered when designing and monitoring interventions and require a deep understanding of behavior and target groups. Interventions should be targeted and based on relevant audience characteristics. Involving the public as a partner in the change process appears to be effective in achieving lasting change. "Learning by doing" is ascribed a key role in the change process.^10,11

It must be remembered that models tend to focus on the personal and social factors that drive change. Additional work may be required to identify influencing factors at the environmental level.³

The process of planning a behavior change intervention involves first understanding the target behavior and selecting a broad approach, and then developing the specific behavior change techniques to be used.16 The “behaviour change wheel” (Figure 1) was developed to guide the selection of appropriate interventions and a “ Intervention Design Tool” are currently under development.^sixteen

Illustration 1. "Wheel of Behavior Change"

Finally, some scholars suggest focusing on social practices (patterns of action that bring together different ways of “doing and saying”).⁴⁶For example, snacking may be related to the social practice of eating while watching television. Observing practices diverts attention from a person's attitudes, behaviors, and decisions, and highlights how particular ways of life are sustained, including the role of governments and institutions. For example, this type of analysis would draw attention to "obese environments" and consider the ways in which diet and exercise patterns are "socially, institutionally, and infrastructural configured."⁴⁶

8. Evaluation of behavior change interventions

Despite the recognized importance of behavior change and the extensive research on the subject, there is no consensus on how best to support specific behaviors. Models and theories should be used and reported in a more coordinated way to facilitate evaluation.³⁵To further advance the understanding of the effectiveness of behavior change interventions, WHO has requested that all initiatives be fully assessed.⁴⁷

Ideally, theory and evaluation flow into the planning of an intervention at an early stage. Behavior change takes time, and the evaluation must be long enough to show that an intervention has resulted in sustainable behavior change. This requires an appropriate allocation of resources.³⁵Whenever possible, controlled trials or other high-quality methods should be used. The randomized clinical trial is considered the gold standard for such evaluations, but is not always possible. Another approach is a "natural experiment," in which the researcher does not control who receives treatment, but instead takes advantage of natural variations in exposure to the event, intervention, or policy (e.g., changing dietary requirements for school meals).³⁵Furthermore, evaluations ideally result in measures of behavior, not just measures of whether participants enjoyed the intervention, not just measures of health changes (which are said to be a consequence of target behavior).¹²It is critical that these measures are consistent across studies and that the details of an intervention are accurately reported.

Evaluations help determine whether interventions are working and, ideally, why they are working. They will also make decisions about how to improve the intervention. You must also assess the profitability of the intervention and thus determine whether it is profitable or not.³⁵It is important that evidence of effectiveness is shared among researchers, policy makers and practitioners to avoid duplication of research and reduce costs.

9. Conclusion

Knowing what works in the area of ​​health behavior change is critical to achieving health improvements and preventing disease. In recent years this has been increasingly recognized and much work has been done to investigate the best approach. There is ample evidence that the use of theory in the design and implementation of health promotion programs improves their effectiveness. However, there is less guidance on which techniques to use. Interventions must not only target behaviors directly, but also help create communities and environments that allow for change. A comprehensive assessment of such interventions is essential to advance our understanding of changes in health behavior.

Education and training (CPD) should reflect the shift in emphasis from simple counseling to the complexity of the behavior and relationship between the healthcare professional and the client. It is important to build the confidence of professionals to apply behavior change techniques. Health professionals are encouraged to seek formal training opportunities to study the principles of effective behavior change and to practice basic techniques.

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