Psychology Of Habit Formation And Sustainable Health Change

Behaviours change is now a core aspect of health care. One of the most effective ways to achieve long-term change is to encourage healthy habits. Chronic disease has become a major public health issue. The need for preventive health care has increased. Digital health technologies are growing at an incredible pace. Clinicians are under pressure to deliver lasting results. By transforming actions into healthy habits, clinicians can improve adherence, boost patients’ confidence and, in the end, achieve more sustainable clinical outcomes over the months and years.

Why It Matters

Health care is moving from “advice in a visit” to “support in daily life.” Clinicians used to think of patients’ typical behaviors as background noise that would cease to be relevant the moment the patient left the clinical office. But with a rising tide of chronic disease, the shift from volume to value, and an ever-expanding array of medications and technologies targeting weight, glucose, and cardiovascular disease, clinicians are now realizing that durable behavior change is essential to delivering good clinical care.

Habits control a lot of the auto-pilot actions we perform on a daily basis, which is why they are so powerful when it comes to managing chronic health conditions. Most actions that promote healthy behavior occur on a daily basis without much conscious effort. Swallowing a tablet, eating breakfast, standing up from your desk, pricking your finger, reading your results, or climbing into bed – all these things happen every day without much thought. Through repetition they can become automatic, removing the need for the conscious process of intention or planning, and eliminating the mental routine of remembering to do something.

As clinical work moves further from bio-medical oriented interventions and instead emphasizes patient’s habits, the clinical work can also become less draining or produce clinician burnout by increasing the likelihood of successful follow- up between office visits. Many of the “short counseling treatment algorithms” fail for one simple reason: The patient returns to the same house, workplace, car, church, neighborhood, school, etc. that set up the original triggers, barriers, and pressures for time. However, the healthy habits design of behavior change reverses the health and illness orientation from “it’s hard to be healthier, so I will try to do better.” to “it’s easier to be healthier, so I will do it well.” This new approach could also prevent many of the unplanned consequences that consume health care resources.

How Habits Form In the Brain

Habits are behaviors that we do in response to specific cues or triggers. The more we do a behavior in different contexts, the more automatic it can become, to the point that the situation in which the behavior occurs becomes the trigger for the behavior. Because habits are automatic, they don’t count on motivation for long-term health improvement.

Following a treatment plan is 90% of the battle. Just thinking about it can be half the battle. I try to think of it in terms of a clinical model of learning behavior: cue, action, reward. First, I try to turn my vague goal into a simple and realistic steps that I can follow. The cue is the trigger for the behavior, the action is what I do when that cue happens (like after I wake up, after I eat, before I brush my teeth). The reward is important, and it should be immediate and meaningful to me. I don’t want to have to wait for a reward, I want to feel it immediately. So something as simple as feeling relieved, or satisfied, or just the immediate sense of completion I get from checking a box on a worksheet is enough. Sometimes I get to call my coach or talk to an app, which is nice too.

Why Small Changes Outperform Big Plans

Change for the better is more enduring when activities are simple enough to do on a bad day. Activities that could be washed out by stress, fatigue, pain, travel, and pressure of time, are not a good choice for health promotion. Tiny plans are repeatable. What starts out as a few seconds, minutes, or hours of activity can be increased in scope over time (from a 5 minute walk to a 10 minute walk for example).

Many people believe that it takes a specific amount of time for a behavior to turn into a habit; that there is a formula that applies to everyone. In reality, the amount of time it takes for a behavior to become a habit can vary greatly from person to person. What it takes to get someone to do a behavior that becomes second nature in a couple of weeks may be entirely different from what another person needs to do the same behavior in a couple of months, or longer. Clinically it may be more useful to ask, “What can help support repetition of this behavior this week?”

Where Technology Helps and Where It Does Not

While digital tools can usefully help people form new habits by reducing friction and timely reminders, there is a point at which an overload of content can actually have a negative effect. This is why methods such as increasing step count, reminders to take medication from a smart pill bottle, and interactive coaching sessions can reinforce healthy habits between clinical visits and provide valuable feedback to both the patient and provider. The tools are most effective when used within a broader care plan that includes well-defined goals, clear escalation procedures, and safeguards to prevent harm.

Equity matters. The most powerful supports for the most powerful habit forming habit—physical activity—are external, and they stem from a patient’s environment. A patient may have the reminder and motivation to take a medication or monitor a condition, but if they don’t have a safe space to walk, easy access to healthy foods, or a stable home, reminders and motivation are not enough. Habit-focused care requires consideration of the social context in which patients live, identifying local resources for supporting healthy habits, and planning for situations that are realistic given the patient’s environment.

Who It Affects

Patients are the major beneficiaries of sustainable health care, and in fact they are the major agents of sustainable change. For those living with diabetes, hypertension, heart disease, obesity, COPD, chronic kidney disease, depression or chronic pain, it is essential to incorporate and adhere to structured routines of medications, nutrition and activity as well as monitoring of sleep, health symptoms and follow-up with healthcare providers. As patients work to build healthy habits, they learn how these affect their degree of daily motivation.

Habit principles apply in family and caregiving situations. Parents apply them when they get their children to sleep on time, caregivers apply them when they schedule and administer doses of medications to frail older patients, and a family with a member who has diabetes is trying to change the eating habits of all family members. Families can help support healthy behaviors and prevent complications by designing the household environment to make healthy behavior change easier to maintain.

This guide is primarily targeted for use by clinicians, and teams of care providers. Their roles are shifting from telling people what to do, to supporting and fostering habits. This guide is intended for use in team settings. Primary care clinicians, nurses, registered dietitians, pharmacists, and behavioral health professionals will develop a treatment plan together, review tracking together, and problem solve together around any challenges that arise. The guide can also be useful to Health Coaches who want to offload some tracking to patients, and have clinicians track other things such as levels of medication, and potential risk to patient or self.

Behavior change has the potential to pay in the long run in reduced health care costs, but requires an up-front investment. Payers and policymakers will weigh the costs of coaching, remote monitoring, and evidence-based digital health programs against the delayed savings realized through reduced complications and hospitalizations. Decisions about coverage, quality measures, and reimbursement strategies for these new technologies will determine whether they are accessible to all who can benefit from them or a luxury that only a few can afford.

Populations With Higher Barriers

Patients with multiple medical conditions and several environmental demands such as food insecurity, shift work, disability, or heavy caregiving responsibilities require more than just motivating them to become healthier. They require more environmental support. Simple habits (micro-habits), more flexible plans (e.g., a healthy eating plan that includes fast foods), problem-solving strategies that involve brief periods of behavior change, meal and physical activity plans that are very convenient and modifiable, and medication routines linked to “invariable” daily anchors (e.g., waking up, bedtime, eating meals).

Mental health and stress load can greatly influence success in developing habits. For some individuals, anxiety, depression, trauma history, or chronic stress can be the greatest obstacle to building healthy habits. By including mental health screening when appropriate and framing slips in context, habit-based care can be truly patient-centered without exposing their emotional pain or failing to address the underlying causes of their behaviors. In some cases, achieving stability in mental health is the first habit individuals need to get good at in order to successfully establish other healthy habits.

What Changes

Clinicians will focus on helping their patients build structure, rather than giving advice. Structure grounds healthy behavior change, making it concrete, measurable, and repeatable. Instead of saying “you need to exercise more” or “you need to eat healthier,” clinicians will help their patients identify a cue, a small behavior, and a quick reward. The behavior doesn’t have to be done perfectly – the key is that it is repeated enough times that it becomes automatic.

1) Practical Habit Design becomes a clinical skill that everyone should learn to use. Most adult problems are caused by bad habits and by making good habits absent or hard to keep.

In addition to writing goals in behavioral language, using the techniques of implementation intentions and habit stacking can also help patients write goals that they can follow. Implementation intentions are “if-then” plans linking situational cues with specific behaviors (e.g. “If I finish my morning tea then I will take my blood pressure pill”). Habit stacking is similar to creating an implementation intention, but links the new habit that you want to build to an existing habit (e.g. “As soon as I have finished brushing my teeth in the morning then I will do two minutes of stretching”). This technique reduces ambiguity (one of the main causes of non-adherence) and means that patients will perform their new behaviours at the same time that they perform their existing habits.

We will work together to design plans that reduce barriers to success and increase cues for positive behaviors, rather than relying on willpower. We can talk about ways to make sure medication is in a place where it is easily taken, filling a water bottle the night before to drive hydration the next day, putting out shoes before waking up in the morning, etc.

2) Teams Expand Beyond the Single Clinician

Long term sustainable change will be supported by having multidisciplinary teams in place and a clear roadmap for effective follow up between clinical visits. This would include ongoing monitoring of success/relapse, troubleshooting of barriers to healthy behavior, relapse prevention and recovery support provided by nurses, pharmacists, dietitians, health coaches and behavioral health providers. Meanwhile, physicians and advanced practice clinicians can focus on diagnosis, stratifying risk, medication decisions and the more complex cases.

Monitoring will become shorter, more frequent and supportive rather than longer, less frequent and critical. Instead of having teams in for lengthy monitoring sessions every 3 months, we will have brief follow-ups every 4-6 weeks. These will be in person or by remote meeting, supplemented by the occasional email. The focus will be on helping teams sustain their great work, to stay on track and build up healthy habits, with as much support as necessary and as little blame as possible.

3) pay models should reward maintenance over initial investment.

Coaching and monitoring are time bound processes and therefore not one day events. Payment for bundle of services, CCM fees, remote monitoring reimbursement and coverage for evidence-based digital therapeutics all need to be included. Otherwise, these features will remain optional and inconsistent.

Future quality measurements will focus on persistence and outcome measures that reflect longer-term quality of diabetes care. These include patients taking their prescribed medication, increasing physical activity, attending follow-up appointments as required, achieving optimal levels of glycemic and blood pressure and weight, quitting smoking behaviour where relevant, and a patient reported quality of life.

4) Patient Experience Is Treated as Clinical Data

Regardless of the situation in which the patient finds themselves, the clinical nutrition practitioner will not perceive lack of progress as a failure on the patient’s part due to reasons of time, cost, burden of caregiving, pain, or safety. The plan will be flexible and can be adapted to fit the patient’s and family’s schedule, living situation, and resources. “Activity snacks” and less expensive nutritional substitutions or approaches will be offered, and a pattern of nutrition plans will be developed that are similar to common, familiar, practical meal patterns rather than an idealistic “perfect” plan.

I find it is a very common oversight to neglect relapse prevention until after the entire treatment has been delivered. Relapse prevention should be a part of your initial treatment plan. After outlining slips, present on the “restart script” for the slipping patient–after just a mini-version of the target behavior for three days, they can go right back to their full behavior. Then, follow up with modules on shame reduction and persistence enhancement.

5) Safety and Shared Decision-Making Are Built In

Combining your strategies for managing common habits with your medical treatment can maximize their effectiveness. For example, if you are treating a medical condition with medication, there may be side effects such as weight gain or loss, changes in blood sugar, or increased cravings for certain foods or substances. Combining strategies for managing habits with these effects with your medical treatment can be very effective. Additionally, it is important to be aware of potential side effects, and have a plan in place to manage them. It is also important to have realistic goals for yourself, and to have a plan for maintenance of weight and healthy habits after you complete treatment.

For example, if you are taking a medication to decrease your appetite, incorporating protein-first meals into your diet, building in reminders to drink water, and following up with your physician or therapist on a regular basis can help you ensure that you are meeting your nutritional needs, and avoid a rebound effect.

Once a patient with chronic medical or surgical problems has been stabilized on appropriate therapy, treatment can transition to step-down therapy. Once remission or improvement is obtained, a patient would be placed on less intense but continued maintenance medication with more frequent office visits to protect remission and promptly detect relapse. This is especially important for patients whose schedules and lives may be changing, (e.g., students graduating, new work assignments, travel, home expansion or contraction for children, changes in work or family for parents of adolescents).

Looking Ahead

Future health interventions will incorporate elements of health coaching, technology and pharmacology, but the bottom line will remain healthy habits. By integrating artificial intelligence (AI) into interventions, timely prompts and adaptive programs can guide users in making healthy choices, and health behaviors can be measured and tracked on a regular basis. Technology, however, is only as good as the human support that backs it, with personalized service, cultural relevance and problem-solving skills on call for those times when the routine of daily life is disrupted.

So now what? For the clinicians and health leaders, the next steps were things like: Treat habits like skills. Pick one priority behavior at a time. Make a tiny habit for the person based on what’s realistic for them. Make sure that the behavior is linked to an obvious cue. Measure performance on whether or not the person performs the habit (and does not blame excuses) as opposed to whether or not they performed the habit perfectly. Make a plan for relapse (and implement it) BEFORE you talk to the first patient. Hold your teams to an organized and structured system of following up on patients. Use technology to remove friction only when necessary.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC10073220/