Changing health behavior requires a hard commitment to the long game: To win important battles against chronic conditions like diabetes, depression, or high blood pressure, patients must sustain a routine of health behaviors, track health markers to manage their conditions, and incorporate new feedback and strategies that can extend months or years.
Outside of periodic visits and check-ins with providers, people have managed these challenges on their own over the years. But the emergence of new mobile apps and other digital tools, designed to improve individual health behavior, is giving patients a source of continual encouragement and interaction to support the outcomes they seek—whether it’s keeping off those pounds they worked so hard to lose, or getting significant relief from chronic pain.
These new digital care programs—supported by behavior science and human caregivers and coaches—offer “an incredible opportunity to meet people in the ‘in between,’ in the moments where important changes are happening for them,” said Jennifer La Guardia, Ph.D., director of clinical product and behavior science at Omada Health.
In a recent interview, La Guardia explained some of the science behind these new approaches, as well as the misconceptions about human motivation they must avoid to be successful.
behavior depends heavily on managing a person’s motivations
Many of the most important behavior changes happen in between visits with caregivers
Incentives and “nudges” can be effective short-term, but don’t have a lasting impact on health
Behavior science has many applications in finance and other industries. How well
understood is its role in healthcare?
Behavior science has been part of in-person care in a pretty robust way for many years. There are studies from 20+ years ago that illustrated key principles around motivation, emotion regulation, and behavior change. But it’s only in the last 10 years or so we’ve really seen an explosion in the translation of those into digital health. There are also companies that design new digital apps and interventions that don’t focus on behavior science, but I think that’s why in many cases they don’t work.
Jennifer La Guardia, Ph.D.
Director of Clinical Product and Behavior Science at Omada Health
Dr. Jennifer La Guardia is director of clinical product and behavior science at Omada Health. She is a behavior scientist, clinical psychologist, and educator with over 20 years experience promoting motivational approaches to health behavior change, management of chronic illness, and improving personal well-being. She is also an expert in Self-Determination Theory (SDT), one of the leading psychological theories on motivation.
What makes behavior science-based interventions so different?
To make health behavior changes that last, you have to be thinking about motivation over the long term and the components of behavior change that sustain it. It’s not simply a “nudge” or the incentives you might apply when you want to achieve a discrete ending or short-term outcome. It’s different in health behavior—it’s an ongoing activity, a process that you have to continue to maintain and attend to. When health interventions don’t account for that, they tend to focus on quick wins. That’s why you see fad diets where people can often make big changes quickly, but they’re not sustainable because the changes haven’t really been integrated into their lives. They might be able to go without carbs for a few months, but once they start integrating them back in, it doesn’t work. If you think about why these ideas don’t necessarily translate in a clinical setting when you deliver in-person care, it’s often because clinical care happens only in short meetings. The actual change that needs to happen occurs in between the time you meet your caregiver and the next time you see them again—in those moments you’re making a decision around eating that cookie or when you’re having an emotionally tough day.
How do digital apps and programs accomplish that?
You need different approaches. First is a bottoms-up, individualized approach, where you iterate and create an intervention based on a person’s inputs. You want to have it make sense to the person and be easy and well-organized. You design it so that patients feel seen through the inputs they provide, and then you can tailor and personalize and iterate on an experience just for them.
But making health behavior changes is hard, and many people aren’t sure how to approach behavior change. They haven’t yet figured out a formula for what will be sustainable. So you have to combine it with guidance based on science—provide a structure for people that explains how behavior change actually happens. If you give people a roadmap and choices about how to engage, they can orient around how to go about making the change. You have to give them the building blocks of being able to make sustainable changes.
How do you measure or evaluate success of digitally based programs when immediate change doesn’t happen overnight?
Engagement is an important thing to measure, not just how many times you click into an app, but how much effort you are putting into trying out actual behavior changes. That said, you can also measure health benefits from seeing how people are making small, incremental changes towards different behaviors. One person might not lose a ton of weight, but if they’re walking more and they’re eating healthier, that’s going to have a benefit to long-term health.
When you dig in, you find people have multiple motivations driving them toward a goal.
Reduce risk for disease
Be more mobile
Feel better in their clothes
Have more energy
Have less pain
So how do you define the right goals?
Many programs pay attention to the markers that are important in terms of business and lowering costs, but often don’t pay enough attention to what’s most important to patients in terms of their own goals.
Most people who join a weight-loss program will say they want to lose weight because it’s a common goal. But when you dig into that more, you find there are other goals that they really want. They want to feel better in their clothes or feel better about how they look. They want to reduce their risk for disease, be able to be more mobile, or have less pain or have more energy.
Often, those things are tangible markers that help them to stay engaged. When we pay attention to these issues that make sense to them, it can help them to see progress—even if the number on the scale isn’t moving.
There are new digital applications and chatbots designed to “nudge” people to make better decisions and change behavior that way. How is that different from the approach you’re talking about?
Concepts like “tiny habits” and nudges are ideas that feel compelling and receive a lot of attention, but they generally don’t have a long-term impact on health. Many of those applications are based on the idea that if I just push you or pressure you to make a change in small ways and I get you to practice that, it will translate into long-term behavior change.
Problem is, we know a lot from science about motivation. When people feel pressured to change—by your spouse or your doctor or even by fear—the changes are short-lived, and only last to the extent that that pressure is still present. In fact, some people react to the pressure by disengaging from the behavior completely. Think of the angry teenager who is done being nudged or pushed to do something. They either dig in and absolutely don’t do it, or they do the opposite.
We all have the angry teenager inside of us. You have to be able to tie motivation to other things that are meaningful to the person, like, bigger-picture life goals such as being able to more easily play with their kids or keep up with activities with their friends, or else it’s not sustainable.
How do you shift patients’ mindset from focusing on fear of failure to focusing on success?
I try not to use the words success or failure, or even to focus on simply reaching an outcome. Many people have gotten stuck in the idea that you either reach an outcome or you don’’t. If you meet your long-term goal for your weight loss, that’s success, and anything short of that is failure.
The problem is, if a patient doesn’t reach a goal, they don’t see it as just failing at a particular task. They will think, “I’m the failure. I’m no good. I’m not ever going to lose weight, I’m never going to be healthy.” When I work with patients, and even with the coaches, we talk about helping people to recognize the strengths that they have in those moments, and focus on building that muscle to be resilient in those moments and learn from their experiences. Those learning moments are what creates change.