gms | German Medical Science

Introduction: Most interventions for health behavior change among patients with different types of diseases have been based – if at all – on theories that primarily focus on influencing cognition or knowledge (i.e., health literacy). These cognitive behavioral interventions are often costly, unsustainable, or both. Recently, dual-process models have been proposed in the psychological and neuroscientific literature which approach automatic processes within the brain’s motivation and reward circuitries, which are usually non-cognitive, i.e., non-reflective yet affective, with promising directions to also inform health behavior interventions, such as digital nudging tools.

We aim at developing a health behavior change model that explains the likelihood of lifestyle change in diabetes type 2 patients, to serve as a base for both digital and analogue behavior change interventions.

Methodology: We review the psychological, neurobiological and behavioral economic literatures on behavior change. Most models focus on conscious processing, while more recent literature provides valuable insights into the non-conscious – emotional or affective – aspects of behavior change, i.e., reward physiology. Common facilitators for healthy action can be fostered even without the patient’s conscious effort involved, yet activating covert resources. We analyze different stages of change relevant to diabetes type 2 patients and identify stage-specific exogenous and endogenous resources. To test the model’s validity, we will conduct a survey among patients and apply econometric analyses.

Results: We suggest a dual-process multi-stage health behavior change model for diabetes type 2 patients that allows for discontinuity in the process of change. The stages are: non-awareness, awareness, contemplation, planning, initiation, continued action and maintenance. At each stage, the patient requires different psychological, biological and socio-environmental resources to progress from one to the other. Endogenous resources are particularly prone to change, and the lack or weakness of one or more of those required endogenous resources can be overcome through three different types of behavior change techniques (BCTs): facilitating (provision of external resources), boosting (reflective resource build-up) or nudging (affective resource use). All interventions activate positive affect and reward systems and thereby assist the patient to overcome barriers and generate or sustain new healthy habits. Each BCT leads to different degrees of patient empowerment.

Conclusions: Both reflective and affective processes are relevant to health behavior and play different roles at the various stages of change. Ideally, interventions in this regard should be tailored to each stage to be effective. Such interventions have the potential to reduce the costs of diabetes treatment, decrease diabetes prevalence, increase patient empowerment and well-being. Future research needs to confirm the proposed model.