Behavior Change and Maintenance
Throughout the life span, the health effects of social and behavioral factors such as smoking, drinking, physical activity, and diet have been dramatically demonstrated. These behaviors have implications for a wide array of health outcomes for both women and men, including: cancer, infectious and allergic diseases, osteoporosis, diabetes, heart disease, arthritis, depression, periodontal diseases, obesity, and kidney diseases, as well as related outcomes, such as mood, functional impairment and disability, quality of life, and health care utilization. Behavior change, therefore, is critical to the prevention, management, and treatment of many important health conditions.
However, the initiation and maintenance of behavior change can be very difficult, and even those interventions that succeed in controlled clinical trials do not always scale well. It is not enough for behavioral and social scientists to do rigorous research and develop effective interventions; there must also be delivery channels and systems in place to disseminate these interventions to the public, policymakers, and other decision makers to ensure that they are implemented, adopted, and maintained.
Health Behavior Initiatives
Translational Behavioral and Social Sciences: There has been consistent difficulty in rapidly translating basic science discoveries into effective interventions. One method of overcoming this issue is to create a pipeline, similar to the model in employed by the pharmaceutical industry, in which the translation of basic science can be supported as it moves to intervention. Behaviors such as smoking, sedentary lifestyles, unhealthy dietary intake, alcohol or substance abuse or dependence and poor adherence to medical and behavioral treatments are major contributors to cardiovascular disease, cancer, type 2 diabetes and other chronic conditions. For example, the combination of excess energy intake and lack of physical activity in the U.S. population over the past several decades has produced a rapid rise in obesity that threatens to reverse recent gains in life expectancy. At last estimate, 40% of premature deaths can be attributed to preventable behavioral factors, and therefore, the single greatest opportunity to improve health and reduce premature deaths lies in personal behavior (Schroeder, 2007).
Studies such as the Trials of Hypertension Prevention, Weight Loss Maintenance and the Diabetes Prevention Program have shown that behavioral interventions can improve behavior and prevent disease. However, even the most successful behavior change interventions are limited in their ability to induce significant, long-term behavioral changes in the majority of adults. Often change occurs only for the highly motivated and is limited to a single health behavior rather than multiple behaviors. Furthermore, even individuals committed to behavior change find it hard to maintain healthy behavioral patterns over time. For example, most smoking studies show a pattern of relapse and cessation that may continue for years
Exceptions to this pattern have been found in preventive interventions, such as the Nurse Home Visitation Program, that have shown lasting and long-term effects. In addition, some prevention research suggests that the greatest gains can be made with those at most risk. But even these successes are not as common as they should be and points to the need for innovative, high quality behavioral research is needed in both the prevention and intervention areas.
As with development of more effective drugs, surgical techniques and medical devices, the development of more powerful health-related behavioral interventions is dependent on improving our understanding of human behavior, and then translating that knowledge into new and more effective interventions with enduring effects.
One way to do this is through an innovative intervention development process, for the behavioral and social sciences, that is analogous to Type I translation in the biomedical sciences, with the ultimate goal of achieving greater effectiveness for health-related behavior change strategies.
Translational research can be defined as the process of applying ideas, insights, and discoveries generated through basic scientific inquiry to the treatment or prevention of human disease, and is often characterized as either Translation I (T1), in which basic science discoveries are used to develop new interventions for disease (bench to bedside), or Translation II (T2), which is aimed at improving utilization of proven interventions in clinical practice and community settings (bedside to public health).
In pharmacotherapy development research, translation I research (treatment development) includes the conduct of small human trials or series (Phase I & II clinical trials) in which data on the safety of the drug and the dosages needed to affect biomarkers of the disease being studied are collected. In Phase I safety studies, the purpose is to gather information on which dosages are well tolerated by patients with minimal toxicity; in Phase II studies, the goal is to test for and characterize effects of the treatment, for example, to determine the amounts of treatment needed to produce biologic responses, such as reduction in the size of a tumor or lesion. If the treatment is found to be safe and effective in altering disease-related biomarkers in these early phase studies, large-scale randomized clinical trials or RCTs (Phase III studies) are then conducted to test the effects of the treatments developed on morbidity and mortality outcomes. Often, prior to instituting a full-scale RCT, a pilot or feasibility study is conducted in the population and setting of interest in order to assess feasibility and acceptance of the approach used, refine intervention and measurement procedures, gain experience in and information concerning screening, recruitment and retention of the target population (e.g., estimates of yield, pre-testing of screening/recruitment procedures), and determine estimates of variability and levels of response in the target population. The same translation process can be applied to the development of behavioral treatments or interventions. For example, Translation I (intervention development) research in the behavioral and social sciences is a phased approach aimed at determining the Phase I safety profile of a treatment, the dosages required (i.e., intensity, frequency, duration of intervention) to effect change in the intermediate outcomes of interest, and in Phase II to identify whether and how a treatment works in specific patient groups under well-specified conditions, and the feasibility and acceptance of the intervention in the target population. This work would culminate in Phase III trials that would test the intervention in a large-enough sample of patients to determine its effects on health outcomes.
To support the translation of basic behavioral and social sciences into effective interventions, NIH has released a new program announcement, PA-11-063, Translating Basic Behavioral and Social Science Discoveries into Interventions to Improve Health-Related Behaviors (R01). This funding opportunity announcement encourages highly innovative research projects that propose to translate findings from basic research on human behavior into effective clinical, community, and population-based behavioral interventions to improve specific health-related behaviors and/or prevent and reduce problem health behaviors. Please see the full announcement at http://grants.nih.gov/grants/guide/pa-files/PA-11-063.html. Additionally, for highlights of the specifics areas of interest for each of the participating Institutes and Centers, please see: http://obssr.od.nih.gov/scientific_areas/health_behaviour/behaviour_changes/translater01.aspx
Science of Behavior Change: Human behavior accounts for almost 40% of the risk associated with preventable premature deaths in the United States. Health-injuring behaviors such as smoking, drinking, and drug abuse, as well as inactivity and poor diet are known to contribute to many common diseases and adverse health conditions. Unfortunately, there are few tried and true approaches to motivate people to adopt and maintain healthy behaviors over time. It is difficult for people to begin to change unhealthy behavior, even when they intend to do so and even more difficult for them to maintain positive behavior changes in the long run. Effective and personalized approaches to achieve sustained behavior change are typically outside the routine practice of medical care. We often use terms like “willpower” and “self-control” to explain behavior change, although the underlying biological, social, and cultural contexts for these terms are not clear. It is clear, however, that understanding the basic underpinnings of motivation change across a broad range of health-related behaviors can lead to more effective and efficient approaches to behavioral intervention and ultimately improve the health of our nation.
In 2009, the NIH Common Fund launched the Science of Behavior Change initiative through a state of the science meeting that brought together over 100 experts in the field to highlight areas of behavior change research in which investment was needed (see Science of Behavior Change Meeting). The meeting yielded specific suggestions program to improve our understanding of human behavior change across a broad range of health-related behaviors. The program supports research that integrates basic and translational science and cuts across disciplines of cognitive and affective neuroscience, neuroeconomics, behavioral genetics, and behavioral economics. The program establishes the groundwork for a unified science of behavior change that capitalizes on both the emerging basic science and the progress already made in the design of behavioral interventions in specific disease areas. This will be accomplished by supporting basic research to improve our understanding of human motivation and maintenance of behavior change across multiple diseases and conditions, and using this knowledge to develop more effective and economical behavioral interventions. See the NIH Science of Behavior Change website for more information and a list of the grants funded with this initiative (http://nihroadmap.nih.gov/behaviorchange/).
Health Maintenance Consortium: In 2003, the Health Maintenance Consortium (HMC) was formed via a five-year research grant from the National Institutes of Health (NIH) and has been coordinated by the Office of Behavioral and Social Sciences Research (OBSSR), The common goal of the HMC has been to understand the long-term maintenance of behavior change as well as effective strategies for achieving sustainable health promotion and disease prevention activities. The work of the Consortium has brought together experts in the behavioral health field who have helped identify and discuss various theories and methodologies related to the processes of behavior change. More information is available at: #. Examples of the HMC work were recently highlighted in the American Journal of Health Behavior Special Issue on the Maintenance of Long-Term Behavior Change. This special edition articulately describes a decade of research on long-term behavior change and maintenance. Prior work had consistently shown that well-designed behavioral interventions can result in meaningful behavior change.
Descriptions of Funded Research
If you are interested in identifying research funded by NIH in this topic area, explore the NIH RePORTER database at the NIH RePORTER website. In order to optimize the search strategy, since no single CRISP search term exists for long-term behavior change, utilization of the combined terms behavior, maintenance, and human can provide an appropriate start for your search.
OBSSR has current funding announcements focused specifically on behavior change. To support the translation of basic behavioral and social sciences into effective interventions, NIH has released a new program announcement, PA-11-063, Translating Basic Behavioral and Social Science Discoveries into Interventions to Improve Health-Related Behaviors (R01).Please see the full announcement at http://grants.nih.gov/grants/guide/pa-files/PA-11-063.html. Applicants interested in submitting a grant application may also follow this link to a listing of announcements for unsolicited announcements: http://grants.nih.gov/grants/guide/parent_announcements.htm