The Evolution of Behavior Change

Christine Maldonado, PhD, Health Behavior Change Specialist

To meet its national goals for cardiovascular health by 2020, the American Heart Association touted a new prescription for health. They branded it Life’s Simple 7. Simply put, it recommends that we:

  1. Eat better.
  2. Exercise more.
  3. Quit smoking.
  4. Control cholesterol.
  5. Manage blood pressure.
  6. Reduce blood sugar.
  7. Lose weight.


That’s it. With little financial investment and limited trips to the pharmacy or doctor’s office, we all could see significant improvements in our health. In fact, middle-aged adults who adopted some—not even all!—of Life’s Simple 7 enjoyed a 67% to 84% lower risk of subsequent cardiac events than their peers who did not.

Beyond the population health implications, the case for financial support of evidence-based health behavior change interventions has never been clearer. In America alone, 75% of our $3 trillion healthcare expenditure is related to chronic diseases—spending that is significantly reduced by Life’s Simple 7. The most recent AHRQ data reveal that Americans with five or more chronic conditions make up only 12% of the population but account for 41% of total healthcare spending. If we as a system could make just a small dent in this problem, the potential to help millions of people—and save a substantial amount of money—is staggering.

Motivation Through Innovation

Healthwise took up this problem to support the behavior change goals of both our clients and consumers. Organizationally, we agreed it was not enough for the content we produce, the programs and products we plan, and the user experiences we create to be medically accurate, but that they also must incorporate behavioral science to address health behavior change goals. Five years later, we can report that our organizational effort to incorporate behavioral science in our offerings is one of ongoing success and ever-evolving innovation.

One pillar of our content strategy from chronic condition management is the Sustainable Change Sequence Model. This model outlines five stages that people must work through to successfully cope and live with a chronic condition. Within each stage, specific behavior change techniques that are known to be most effective at certain stages are outlined. Much like you must match a drug (statin) with a condition (high cholesterol), we know that certain behavior change techniques (e.g., action plans) are more effective at specific stages of readiness to change (e.g., behavior stage).

Patient-Centered Strategy

All the behavioral science in the world won’t help the dissemination and uptake of an intervention if it’s not patient-centered and respectful of choice and autonomy. Delivering these behavior change techniques within a motivational interviewing context is a practical and empathetic process that recognizes how difficult it is to make life changes. When the content offers stage-specific prompts (readiness and confidence rulers, values discrepancy exercises, and action planning), it encourages self-reflection and supports motivational interviewing-compliant coaching.

We also draw from the field of behavioral economics to creatively “nudge” people toward healthy behaviors. For example, the principle of choice architecture tells us that when people fill out a form, the length of a person’s response is influenced by how much space they have—the more space you give, the more a person will write. Thus, when we created healthy grocery list templates, we allowed more space in the “fruit and vegetable” section relative to the “healthy fat and oil” section. Likewise, people are far more motivated by short-term and concrete benefits than distant, abstract ones. When we talk about the benefits of physical activity, we highlight rewards that happen immediately following a workout (stress reduction or spending time with a friend) rather than citing delayed benefits (weight loss) that a person will not likely achieve for some time.

This strategy results in content suites that are informed by the best behavioral science to support people in making behavior changes to manage their chronic conditions and health. From a technical standpoint, all content that’s supported by behavior change is tagged with metadata that identifies the piece as part of a particular stage and using a particular technique. This allows nurses and health coaches to filter search results by behavior change stage. Not sure which stage best describes a person? No worries—we offer a 6-question assessment to help identify which stage fits best, as well as what types of coaching approaches would be most helpful at this specific stage. By knowing this information, the coaching experience and the educational fulfillments can be tailored to meet a person at their behavioral stage.

Much like health behavior, our work is ongoing. We are setting new goals for ourselves in how behavior change can be supported as we create new products and offerings. For example, we are brainstorming ways that the new Content Browser can allow our CaaS clients to search for our content by behavior change stage. When we think toward modern delivery vehicles for content (e.g., chatbots) and relying on machine learning to deliver interventions, we look to lessons learned where applied behavior change techniques fell flat and when they triumphed.

The science of behavior change in tandem with techniques and technologies that allow targeting and interventions can improve health outcomes and reduce care costs. To learn more, read our eBook, Behavior Change: Improving Outcomes by Guiding People to Success.