Column Editor: Connie Mester, MP
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In our initial discovery of what compels a person to behave or act we examined how motivation, intention, and autonomy influences, predicts, and drives behavior. Uncovering that people behave based on a need that can be influenced, predicted, and driven by personal choice seems obvious. But if this is so clear, why is behavior change so hard to understand and motivation so hard to stimulate?
In the second part of this series, will look at what it takes for a program to motivate action and inspire people to perform behaviors and reach their desired outcome. We will consider if mobile applications [mHealth] can truly have an impact and stimulate the adoption of healthy behaviors. Compromising behaviors can be difficult to change, regardless of a person’s intent to change for the better (Schwarzer, R. et.al., 2008). How does a person who is not motivated gain the motivation to create an intention to change their behavior? What if an individual desires to reach a particular outcome, but fails to take action? How can we activate and motivate people to perform behaviors to reach their desired outcome?
Action + Performance = Outcome
Since we know that a person's behavior accounts for 40% of their health outcome, focusing on positive healthy actions is critical (McGinnis, et al., 2002).
Activation involves the decision to initiate a behavior to satisfy a need, such as signing up for a tennis class to become more physically fit. In the activation process a person defines their present state and what change is needed to reach the new future state. This vision of what can be helps a person set and reaffirm their intentions and can help them imagine how it will feel to reach their goal to keep going in spite of difficulties.
Identifying why an individual wants to achieve a goal (Siegert, et al., 2004) is important to influencing action. Since goals are the centering principle of motivation (Murray, 1938), aligning with an individual’s values and crafting a specific goal, clarifying and prioritizing steps to reach the goal (Schreurs, et al., 2003; Feintstein and Feinstein, 2001) picking one thing to focus on helps to get clear about intentions and maintain momentum when obstacles get in the way. Research shows that health-related, goal-directed behavior is enhanced when goal setting is accompanied by specific planning of behavior (Schreurs, et al., 2003).
Many programs tell a person what to do. However, going beyond describing what, programs must tap into why and then show how, by breaking things down into smaller steps to achieve the larger goal. Clarifying steps and prioritizing and crafting very specific action plans to achieve each goal can support success (Schreurs, et al., 2003; Feintstein and Feinstein, 2001).
Health interventions focused on general goals or prescribed actions, without regard to what the person truly wants, can make lasting change a challenge. You’ve seen the recommendations at the end of health assessments calculating past behavior to show an obvious opportunity for improvement. However, if the person doesn’t recognize the same need or doesn’t desire to see this part of their life differently, then the recommendations will likely fall on deaf ears. When the person decides the goal and is actively involved in devising a plan that realistically incorporates their daily life, they are more committed to strive towards the outcome they desire and see it as valuable (Bandura, 1991).
Individualized programs understand different challenges and personal characteristics such as learning style, personal interests, and past experiences can stimulate motivation. Taking into account external influencers and social and environmental factors can propel or hinder success, and nurture a person’s inner motivation, by incorporating personal preferences and values into activities and avoiding external regulators such as rewards, deadlines, and compliance demands. Social support via encouragement and praise is important reinforcement, especially during acquisition of new behaviors (Rhodes, et.al., 1997). By acknowledging difficulty and recognizing factors that can impede success, people take responsibility for their choices and begin to problem solve ways to overcome barriers and distractions.
We’ve all heard the proverbial expression “practice makes perfect.” Once a person has defined their future state and identified the support they need to overcome barriers that get in the way, they must practice what they have committed to by taking small steps included in their plan to achieve their larger goal. Building new skills and knowledge through repeated practice helps build confidence, boost motivation, and improve self-image, which ultimately influences sustained performance and outcomes. Repetition is key, and lasting change doesn’t allow for short-cuts.
A person’s attitude and the quantity and quality of their performance is a result of their persistence [the amount of effort exerted in pursuit of a goal], capabilities [how well a person can acquire, recall, and use new knowledge and skills], and social and environmental factors that nurture and encourage their success. As people experience small wins and take time to reflect on specific details about their accomplishments, they begin to feel more competent, one of the key needs for personal growth.
Flexible program design can help to satisfy changing needs while also providing options that align with diverse characteristics to positively influence successful performance. Linking the person’s action to the outcome they are striving to achieve helps them to see the impact the small steps are making towards their larger goal. Focusing on the big picture and overall progress, by periodically providing positive, constructive feedback, increases confidence.
Self-management programs that provide routine incentives for completing tasks may gain initial progress. However, to be most effective, reinforcement must empower confidence and self-efficacy in individual capacities and attributes, with responsive and dynamic messaging, not merely provide applause for routine accomplishments. Further, by offering unexpected reminders and variable reinforcement using affirming messages rather than controlling and rigid ones, programs can stimulate a person’s attention and trigger the continuation of positive health behaviors.
A person’s action and performance success leads directly to their outcome. People behave in ways they think will produce a desirable outcome. The things that trigger behaviors are unique to each person, based on their expectations, perceptions, and many other variables that can fluctuate over time with experiences, life events, age, etc. Because of the differences between the ways people are motivated, what influences action for one may not work for another.
A person may react differently to the same situation or reinforcement, suggesting that program design should account for all motivation types. Programs that deliver one single approach likely will fail to make an impact. It is no wonder that the design of effective, efficient, and appealing mobile health programs is a complex enterprise.
Just as personalized medicine uses a person’s genetic make up to formulate an individualized treatment approach, a similar method can be used to align with the unique characteristics of a person and the environment in which they live to design a meaningful health support program.
Mobile health has emerged as a way to deliver health behavior change interventions that can be adjusted or tailored to individual needs while providing continuous engagement in a person’s everyday environment. Digital health interventions are proven to drive positive behavior change and have an impact on patients’ health outcomes (Sawesi, S., et al., 2016).
In this time of increased access to personalized technology, coupled with a new focus on the importance of health behaviors, it is imperative that programs thoughtfully design around the individual user experience and holistically facilitate meaningful change. Guided self-management strategies readily available on a person’s mobile device provide an effective way to overcome barriers while offering a private, convenient, and economical solution. However, 48% of mobile health users cease using programs within six months (Price Waterhouse Cooper, 2014).
Many existing health apps and wearable fitness devices in this multibillion dollar mHealth market motivate the already motivated, offer only extrinsic rewards, or provide data on calories burned, miles walked, heart rate, or hours slept, with little personal direction on how these actions impact one’s health and what changes are reasonable to integrate into a daily routine (Bajarin T.,2014).
Data delivered to a user without consideration of the spectrum of motivational needs fails to meet the individual where they are or create meaningful behavior change. To be successful, a program must validate positive behavior, provide encouragement through milestones, guide the user to seek out social support, adjust to meet each person where they are, and provide tools to catalyze progression. Ultimately, a program to change motivation must start with one thing: the individual.
The next generation of mHeatlh holds great promise as a tool for addressing many pragmatic challenges and offers a more empowered style of engagement. As these apps and games continue to evolve and include interactive and adaptive sensors and other forms of dynamic feedback, they must engage the person in the greater purpose to truly influence sustained behavior change.
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References
- Schwarzer R and Luszczynska A. (2008). How to overcome health-compromising behaviors: The health action process approach. European Psychologist, 13(2),141.
- McGinnis JM, Williams-Russo P, and Knickman JR. (2002). The Case For More Active Policy Attention To Health Promotion. Health Affairs 21, no.2 (2002):78-93 http://content.healthaffairs.org/content/21/2/78.
- Siegert RJ et al. (2004). Toward a cognitive-affective model of goal-setting in rehabilitation: Is self-regulation theory a key step? Disability and Rehabilitation, 26(20): 1175-1183.
- Murray HA et al. (1938). Explorations in Personality. New York: Oxford University Press.
- Schreurs KM et al. (2003). Development, content and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviors. Patient Education and Counseling, 51: 133-141.
- Feinstein RE and Feinstein MS. (2001). Psychotherapy for health and lifestyle change. JCLP: In Session: Psychotherapy in Practice, 57(11): 1263-1275.
- Bandura A (1991). Self-regulation of motivation through anticipatory and self-reactive mechanisms. Perspectives on motivation: Nebraska Symposium on Motivation. Vol. 38.
- Rhodes Fet al. (1997). Using behavioral theory in computer-based health promotion and appraisal. Health Education and Behavior, 24(1): 20-34.
- Sawesi S, Rashrash M, Phalakornkule K, Carpenter JS and Jones JF. (2016). The Impact of Information Technology on Patient Engagement and Health Behavior Change: A Systematic Review of the Literature. JMIR Medical Informatics, 4(1), e1. http://doi.org/10.2196/medinform.4514
- Price Waterhpuse Cooper (2014). Emerging mHealth: Path for growth. Available at http://www.pwc.com/en_GX/gx/healthcare/mhealth/assets/pwc-emerging-mhealth-chart-pack.pdf.
- Bajarin T. (2014). Where wearable health gadgets are headed. Time Magazine, online. Available at http://time.com/2938202/health-fitness-gadgets/.