Key principles of Health Behavior

Devising programs that help people make lasting behavioral changes in their health is difficult. But countless studies show why it’s the key to a brighter future for healthcare, especially for millions of people who suffer from chronic health conditions, which account for 90% of all healthcare costs in the United States.*

While the science of behavior change has been well-established for decades, the modern discipline of applying behavior science to clinical care, in tandem with personalized digital tools, apps and analytics—is not well-understood by employers, HR and benefits leaders, or patients themselves. Although behavior is typically perceived as a function of the individual, for example, health behavior is influenced by multiple factors, such as a person’s social and physical environment, their neighborhoods and communities and cultural norms.

This guide explores some of the fundamentals of health behavior, such as the increasing responsibility of employers to invest more in these types of programs; the complexities of managing human motivation to create sustainable change; the mistaken assumptions about health behavior that are handicapping adoption and progress; the symbiotic partnership between human coaching and digital health apps and tools; and how to approach measurement and ROI calculations of health behavior programs and interventions.

Stanford health researcher Jeffrey Pfeffer explains how and why employers need to step up

Researchers have known for years that behavior change is one of the most effective ways to improve outcomes for the millions of people with chronic health conditions—and to bring down skyrocketing healthcare costs in the process. But employers and benefit leaders need to do more to invest in modern health-behavior programs, says Stanford health researcher and author Jeffrey Pfeffer.

One of the biggest misperceptions about health behavior is the belief that human willpower and self-control are the catalysts of great outcomes—and that some people have it, while others don’t.

“Behavior change requires repetition that’s not easily handled by willpower, simply because it requires us to persist,” says Wendy Wood, director of the Wood Habit Lab at the University of Southern California and author of “Good Habits, Bad Habits, the Science of Making Positive Changes that Stick.” “Habit memories form and change very slowly, and establishing one requires a lot of repetition.”

To make that possible, Wood says, it’s necessary to identify the obstacles to the desired change and get rid of them—“reducing friction,” as she says.

Need help sticking with a diet? Then map a new route to work that doesn’t pass your favorite doughnut shop. Or choose a seat further from the bar to make it harder to order another round. Park closer to the stairs than to the elevator to get more exercise. Setting up your environment to help promote the behaviors you are aiming for helps create lasting change.

Many motivational wellness programs are based on set schedules and clearly defined goals, from six-week weight-loss challenges to 10,000-steps-a-day exercise regimens.

But they often backfire, as employees push themselves to meet an immediate objective and don’t make the small yet important changes to their routines that lead to sustained weight loss or alleviate stress, and they don’t learn how to tackle new challenges or bumps in the road. They can quickly become discouraged and toggle back to old habits.

Science shows that quick wins are attractive but dangerous illusions. Some behavior changes take longer to instill than others, and times can vary widely from person to person.

Rather than asking participants to stick rigidly to a plan, health behavior programs are more likely to succeed when they build in flexibility and treat “failures” as an opportunity for self-knowledge.

“If we help people learn to treat these setbacks as expected moments that require reflection, compassion and problem-solving,” says Megan Call, a professor of psychiatry at the University of Utah School of Medicine, “we increase the chances of changing a new, helpful behavior into a habit.”

The dismal success rates of stop-smoking campaigns and government nutrition programs make one thing clear: Simply informing someone about the dangers of unhealthy behaviors and the benefits of healthy ones has little or no effect on behavior.

What about tools designed to guide people to healthier actions, such as meal-by-meal diet plans or weekly workout schedules? By themselves, they aren’t much more effective than information campaigns. They need to be accompanied by continuing guidance on how best to use them.

Instead of lectures, people need to understand why losing weight or exercising more is meaningful for them. And fixed meal plans and workout programs don’t help when someone experiences inevitable setbacks that can cause them to drop out.

“There are new choices and variables all the time that impact health behaviors, like it’s snowing outside or they get an injury,” says Jennifer La Guardia, director of clinical product and behavior science at Omada Health. “We need to equip them to be ready to respond to any setback or challenge.”

The path to better health is littered with good intentions and billions of dollars. Consider the year-end ritual of committing to a new fitness regimen or to quit smoking, only to snap back after a few attempts, then repeat the failed ritual 12 months later.

Aiming to solve this problem and armed with data that proves human behavior can be redirected with the right combination of interactions, information and coaching, new digital health programs and apps to support these goals have exploded in recent years. More than 1.4 billion people are expected to use them by 2025, according to Jupiter Research.

A central feature of many of these offerings is the “nudge” ideally designed and personalized motivators, prods and reminders that can create lasting behavior change. (Think of a personal message from a coach or a caregiver, congratulating you after logging a workout or taking your medication on schedule.) Or, they can create no change at all, if targeted or delivered the wrong way. (Think of a health app prodding you relentlessly to take a lengthy quiz.)

Here’s a look at three types of behavioral nudges, and what makes them effective.

Anyone who’s used a fitness app knows about reminders: text messages or device notifications tied to a program you’ve signed up for. A reminder might ask you to weigh yourself each morning and record the data.

The outcome of the reminder—a reward in the form of helpful information—is critical to success, says Gary Bennett, a professor of psychology and neuroscience at Duke University.

“If we do it well, we give you insights about yourself and make it easier to make those changes yourself,” he says. For instance, it matters how long after stepping on the scale that participants get something in return. “You’ve got to minimize that time between the information and the prize,” says Bennett.

Massachusetts General Hospital used reminders to support patients undergoing lumbar spine surgery; the system sent patients messages about healthy behaviors before and after their operations. Readmission rates, an important measure for hospitals, decreased 75%.

From FitBit to the Apple Watch’s many apps, there’s no end to an individual’s options for keeping, compiling and monitoring health data. But do they work?

As behavior nudges, activity trackers can be effective in surprising ways: A review of data from 8,500 medical and pharmacy claims showed that people who used health trackers for steps, sleep, weight or diet were significantly more likely to stick to their medication schedules. Another study found that the use of digital trackers increased the amount of exercise by overweight postmenopausal women by 38 minutes per week.

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.

Benefit planners and others should focus on managing motivation to change individual behavior, says Jennifer La Guardia, Omada Health director of clinical product and behavior science.

Measuring health behavior is far more difficult than advertised. But getting it right is critical for health programs to succeed.

Benefits managers spent nearly $50 billion in 2019 on employee wellness programs, which are largely seen as a brake on skyrocketing healthcare costs.

While the programs have shown some success in getting employees to exercise more and watch their weight, recent studies have found that many have no significant impact on important measures of success, such as lower cholesterol, reduced healthcare spending, less absenteeism or improved job performance.

Benefits managers commonly look at engagement metrics as leading indicators of a program’s effectiveness—the number of times per day an employee clicks into a fitness app, or how much diet or exercise content they’ve consumed. The problem, healthcare professionals say, is that engagement data doesn’t signal whether people are adopting new behaviors that lead to meaningful changes.

“There’s a tendency in digital health programs to try to generate more engagement under the hypothesis that more engagement will inevitably lead to better health outcomes,” says Ryan Quan, director of data science at digital care provider Omada Health. “But our data shows that engagement quantity isn’t the key to outcomes; instead, it’s a combination of the consistency and quality of that engagement that matter at least as much.”

Digital wellness programs don’t work very well without the help of human coaches and peer-group communities. A far better predictor of success is how consistently employees engage with the coach or a community of other participants

Traditional measures of health program outcomes, like first-year ROI and healthcare savings, can be useful, but they don’t always describe or capture meaningful health improvements. They can also be misleading.

One study in 2013 of a wellness program at a Missouri hospital system found that while it reduced in-patient costs, other expenses rose, and the employer saw no net savings. At the same time, hospitalizations for conditions targeted by the program were 41% lower than for members in a comparable group—a significant benefit for those who avoided a hospital stay.

Even when a program’s metrics show success, they can obscure the underlying reasons for the improvement.

Another study examined the effects of a digitally based “intensive behavioral counseling” program run by Omada Health. The goal was to help a group of seniors lose weight and reduce the risk of diabetes and other chronic health problems.

Participants reduced their weight on average by nearly 7% in 26 weeks. Researchers estimated that this would translate to medical-spending savings of as much as $1,770 per person in three years and $14,200 in 10 years, or $12,840 after factoring in program costs. The takeaway for health plan managers: Patience pays. “When we look at the trajectory of long-standing behavior change, we see that success builds over time,” says Quan. “The goal of a successful program should be optimizing for the long term.”