Key Highlights and Action Items

This workshop was the first in a series of meetings sponsored by the NIH OBSSR and NIH-wide Adherence Research Network which aims to develop a better understanding of health behavior maintenance to promote and sustain positive health outcomes. 

The workshop focused on advancing the conceptualization of behavior maintenance. While there are many definitions of behavior maintenance, behavior maintenance broadly refers to routinely performing a health behavior over time and, where needed, across contexts. An improved conceptualization of behavior maintenance is important for informing future health behavior research, health promotion programs, behavioral and pharmacological interventions, and clinical practice.  

This virtual workshop was held over two days with a group of invited researchers and NIH staff who hold expertise in health behavior research and collectively work across different chronic illness and health promotion areas, including cardiovascular health, diabetes, physical activity, cancer survivorship, ophthalmology, HIV/AIDS, substance abuse, and mental health. The workshop’s goals were outlined in introductory presentations from NIH OBSSR Acting Director Christine Hunter, Ph.D., ABPP and workshop series Co-Chairs Anne Peters, M.D., University of Southern California, and Alex Rothman, Ph.D., University of Minnesota. Participants subsequently participated in several small- and large-group discussions to identify themes and work toward consensus on a conceptual model of health behavior maintenance, by defining key terms and delineating possible multilevel mechanisms of action.  

Conceptualizing Behavioral Maintenance

• Maintaining behavior change is dynamic and iterative and does not necessarily unfold in a unidirectional or linear manner. The manner in which behavior maintenance unfolds may differ across behavioral domains. The prevailing view of behavior maintenance as the consequence of a series of sequential stages or phases may only hold in a limited set of cases.  
• This dynamic conceptualization of behavior maintenance has not been well represented to date, and many existing models are overly simplified and static. The field would benefit from a framework that aggregates constructs from existing frameworks and advances a more dynamic formulation. There is openness to a major rethinking of existing conceptualizations of long-term behavior change and maintenance processes to increase their utility.
• Important language considerations include choosing verbs rather than nouns to reflect dynamism (e.g., maintaining vs. maintenance), and avoiding stigmatizing language (e.g., relapse, failure). Using metaphors to conceptualize behavioral maintenance may be helpful. 
• A corkscrew or spring model could represent the possibility of both forward and backward progression of behavior changes surrounded by contextual factors that cause tensions on the process of behavioral execution Given the variation in external and circumstantial influences over time, the question remains whether variance in behavioral execution narrows or expands which influences fluctuations from the goal behavior.
• Conceptualizations should attend to the multiple dimensions that are needed to characterize behavior change and maintenance processes. These dimensions may include, but are not limited to, timescale, observable behavior, psychological processes, and moderators that may reflect individual differences as well as social and environmental factors.
• Although there is a need to differentiate between health-related behaviors (e.g., physical activity), health outcomes (e.g., cardiovascular disease risk), and their determinants, these are closely interwoven and can exert bidirectional influence on one another.
• Efforts to change different behaviors may be attempted simultaneously, with different trajectories, and even different mechanisms of action and influences. Change in one behavior can influence change in another. 

Mechanisms of Action for Behavior Maintenance

• Behavior maintenance is guided by factors at the individual and contextual levels and must therefore be conceptualized as a multifactorial process.
• Known individual-level mechanisms of action include motivation, outcome experiences, and identity formation, among others. 
• Because the processes discussed are dynamic, potential mediators can change.  People’s ability to adapt to changing circumstances and switch between mechanisms may support maintenance.
• The groups discussed how to classify factors as determinants or mediators if the absence of an intervention and noted that mediators may play different roles over time and for different people. Some variables (e.g., motivation, disease state, as examples of internal states) may be conceptualized as both mediators and potential moderators.
• There may be opportunities to develop taxonomies or ontologies of mechanisms of action for behavior maintenance because many of these concepts/constructs overlap or share close connections.
• Greater onus should be placed on environmental and structural factors that either promote or present barriers to behavior maintenance. To date, the field has tended to emphasize assessing individual-level factors (e.g., self-efficacy, motivation) relative to factors that capture the contexts in which people live and enact health behaviors, which can present significant constraints. For example, individuals of lower socioeconomic status frequently must navigate around factors that place constraints on their ability and opportunity to maintain key health behaviors. 

Generalizability across disease groups and conditions

• There is value in creating a model of behavior maintenance that identifies the processes that generalize across behaviors and health conditions, while being able to accommodate important sources of variance that emerge across behaviors and health conditions.
• Individuals who experience side effects and adverse health events of a treatment may struggle with behavior maintenance differently from those who do not experience these events. The nature of these effects may be disease, behavior, or person specific.
• Disease-specific stigma can affect factors at many levels, and the costs of treatment adoption, in the context of social norms related to the behavior being adopted, must be considered in the context of behavior maintenance.

Research Gaps and Future Directions

• Consider further development of a model of behavior maintenance that generalizes across behaviors and health conditions, while being able to accommodate important sources of variance that emerge across behaviors and health conditions.
• Advance the articulation of taxonomies or ontologies of mechanisms of action for behavior maintenance, with attention to factors at multiple levels of ecologic influence.