NIH Science of Behavior Change
June 15-16, 2009
Because behavior has large and pervasive effects on health outcomes, better understanding of the mechanisms underlying behavior change promises substantial improvements in public health as well as savings in healthcare costs. For these reasons, advancing the science of behavior change has been identified by National Institutes of Health (NIH) Institute directors as a top priority for NIH-wide research efforts, and interest has been building to bring together scientists from a wide range of disciplines to radically move this science forward. The NIH meeting on the science of behavior change, held June 15 to 16, 2009, in Bethesda, Maryland, represented the coalescing of efforts to help the NIH shape an exciting new research agenda for a cross-NIH, cross-disciplinary initiative on the basic science of behavior change. Over 130 participants attended the meeting, including 60 invited experts who shared their perspectives from fields as varied as psychology, neuroscience, economics, sociology, nursing, biology, medicine, health behavior and health education, public health, epidemiology, gerontology, pharmacology, dentistry, marketing, communication, decision making, computer science, and engineering, as well as 67 NIH staff drawn from 17 Institutes and the offices of the NIH Director. The issues and ideas put forth by meeting participants stimulated innovative thinking and new collaborations aimed at accelerating the transformation of health promotion and disease prevention.
The overall meeting format featured three panels designed to address key areas of behavior change science namely (1) acquisition and prevention of behavior, (2) changing existing behaviors, and (3) maintenance of behavior followed by a breakout session intended to promote integration and develop ideas for future research directions. Each panel was asked to address specific questions about basic social, behavioral, psychological, or neurobiological mechanisms and processes; individual differences that may enhance resiliency and the ability to resist adoption of unhealthy behaviors; whether there are particular developmental windows of vulnerability that may disrupt critical periods for intervention; and examples of efforts to shape social or behavioral environments or alter basic psychological or neurobiological processes in the service of acquisition and prevention, change, and/or maintenance of behavior. There was also keen interest to discuss innovations in methodology that are needed to advance the science of behavior change, the utility of animal models in research meant to inform understanding of the basic mechanisms underlying human behavior/behavior change, and the development of effective interventions and strategies to maximize the development and maintenance of healthy behaviors in humans.
Keynote speakers were invited to set the stage for each panel by sharing their thoughts on the major issues facing applied/clinical scientists, and commentators were asked to provide an integrative summary and response following panel presentations and discussion. To inform future NIH research initiatives, each of the four breakout session groups was asked to consider the areas of research most ready for translation, those research areas most likely to be transformative, and ways to facilitate communication between basic and applied scientists in the science of behavior change.
In considering the clinical and applied issues in behavior, there was concern that basic research creativity not be constrained by end-application considerations. At the same time, increased focus is needed on the latter stages of the translational continuum; that is, the translation, dissemination, and adoption of research findings. In particular, participants called for more basic research into factors that shape health decision making (e.g., cognitive, social, environmental, and developmental) and the conditions under which knowledge leads to action versus inaction. Indeed, behavioral economic and decision research approaches such as manipulation of framing and choice architecture as well as the use of financial incentives to promote behavior change may already be ripe for translation into community-based studies. There was also a call for more policy-relevant research and greater efforts to translate behavioral research findings into policy.
Integrated multilevel approaches to behavior change
The meeting highlighted the importance of projects that link individual- and population-level analyses and the need for multilevel approaches that consider the brain, person, and environment simultaneously and over time. The challenge is how to initiate and maintain health-promoting behaviors that have repercussions at the population level. A profoundly new approach would require an integration of methodology, measurement, and a way of sampling longitudinally at hierarchical levels from the individual to the community to the population (with the appropriate time unit for each level), linking each level to those above and below it.
Behavior "bundles" and the need to target multiple behaviors at once
Behaviors that are clustered or correlated likely have common underlying processes, and considerable support emerged from this meeting for approaches that target multiple behaviors at once, recognizing the difficulty in changing multiple risk behaviors simultaneously. Basic scientists were challenged to offer competing behavioral substitutes and to harness synergies between behaviors to make healthy change easier, incentivize health change without undermining intrinsic motivation, and nudge social networks to spread and sustain healthy lifestyles.
Developmental perspectives on behavior change
Behavior change research should occur within the framework of the human lifespan. For example, epigenetics could be used to identify biomarkers for pivotal biological changes, such as those that occur in response to normal development as well as in response to childhood trauma or stress. Biomarkers for pivotal points of developmental change can be generated by research on neuroimaging, stress endocrinology, genomics, immune/inflammation biomarkers, and psychophysiology.
Environmental context of behavior and behavior change
Participants underscored the importance of studying environmental context of choice and responses to that context, including situational control, stress and brain adaptation, gene-environment interaction, and application of ecological models, behavioral economics, social network analysis, rational decision making, choice architecture, and framing. There also was considerable interest in capitalizing on the dynamics of social networks for technology-based interventions, particularly among adolescents, and for involving target populations in the development of interventions to ensure their effectiveness.
New methods and measurement
Researchers from a wide range of disciplines, including neurobiology, economics, mathematics, psychology, computer science, neurology, and psychiatry, are using computational approaches to study behavior. There was strong support for developing new methods for collecting, simplifying, analyzing, and disseminating complex, dynamic, and multilevel data and for testing models of such data. Mobile personal sensing devices (e.g., mobile phones) for conducting ecological momentary assessments offer potential as cost-effective delivery platforms for population-scale interventions that can compress data collection intervals from months to hours, minutes, and even seconds; in some situations, real-time functional resonance imaging could be appropriate. Participants also indicated there is a strong need to encourage collaborations between methodologists and clinical scientists and between computational and statistical researchers. In terms of measurement, participants called for unified definitions of contextual variables that allow for more precise, robust, and repeatable measures. Funding for methodologists adept with large datasets as well as standards for such measures will be critical to render the information usable for scientists with widely disparate training.
Better understanding of mechanisms
A fundamental barrier to progress in the science of behavior change has been the lack of understanding about the basic mechanisms of behavior change or the mediators of interventions. There is a significant need for more sophisticated examination of behavioral mechanisms of change as an end in itself. Understanding behavioral mechanisms of change will depend on parsing social identity and social context, which will help expose and remedy health disparities. Some considered research on mechanisms to be an area well suited for interface between basic and applied scientists as well as a forum for transdisciplinary work. Theoretical models of health behavior are influenced by a long history of theory and research in decision making, and implementation of health behavior decisions depends on a number of factors that encompass the cognitive psychological domain but also include ecological factors and neurobiological control resources. An example of one area of research on mechanisms of change is work on executive control over behavior to promote healthier behavioral trajectories. Promising research directions in this area could include approaches for augmenting executive control, enhancing metacognition, and understanding the central role of emotion regulation in many problem behaviors.
Behavioral interventions are often expensive and typically not covered by insurers. More cost-effectiveness data, as well as comparative effectiveness data, are needed, and their implications should be better communicated to policymakers. Powerful tools for promoting healthy behavior change include contingent incentives and technology-based interventions that allow complex interventions to be delivered with fidelity at a low cost and to be readily tailored to special populations.
Dissemination of interventions
As behavior research produces more cross-cutting, multibehavioral interventions, better dissemination strategies will become increasingly important for realizing meaningful public health impact. A major inhibiting factor in dissemination is the lack of an effective and seamless delivery system to effectively communicate scientific research to policymakers, providers, and consumers.
Treatment adherence and relapse
There are a variety of areas in which basic science is needed to help improve research on patient adherence and relapse. These include increasing the validity of self-report, augmenting cognitive function and compensatory strategies, determining the relationship between beliefs/attitudes and behavior, improving teaching and learning strategies, and encouraging self-management. Except for lowering the price of copayments, the effectiveness of most strategies employed to encourage adherence is modest. There is a general sense that information by itself is not effective, which may or may not be true, but it is true that for certain populations (limited English language, low-income, etc.), improved methods for explaining conditions and medications are needed. These populations are more likely to be lower in health literacy and numeracy, which have been linked to lower levels of adherence.
Scientific infrastructure needs Advances in the science of behavior change require a transdisciplinary and multilevel approach. Institutional silos, conservative review panels, and lack of an incentive structure are some of the oft-cited reasons why transdisciplinary research does not thrive, and participants considered how the NIH might foster this area. Suggestions included development of a common taxonomy and set of measurements, processes, and mechanisms and sustainable structures for cross-disciplinary collaboration, which is not currently rewarded by existing institutions. How researchers are trained generated considerable discussion. There were advocates for transdisciplinary training and for continuing with unidisciplinary training but enhancing it with exposure to transdisciplinary work, a new feature of some NIH training grants. Participants also called for greater interplay between research on the basic mechanisms of change and clinical interventions. Suggestions for accomplishing this included not only exposing students early in their training to other disciplines but also facilitating repeated basic researcher/applied researcher exposures and collaborations over time; for example, with face-to-face meetings, online databases, and/or virtual networks such as the MacArthur Foundation research networks.
In the same vein, participants suggested that the NIH create funding mechanisms for transdisciplinary teams that are less project focused to allow freedom for iterative development of ideas. In essence, some teams of researchers need a longer incubation period because the science grows from the collaboration rather than the inverse. One suggestion was that small grants with participants from multiple disciplines could foster ongoing, robust research collaborations across disciplinary lines.
The science of behavior change has long suffered from fragmentation along scientific and topical boundaries. The mechanisms underlying effective behavior change strategies often remain obscure, hampering attempts to translate treatments between domains or from controlled trials to populations. Yet because unhealthy behaviors cause so much morbidity and mortality, the status quo cannot prevail. There is, however, renewed hope that the NIH can facilitate progress by supporting research on basic mechanisms of behavior change and by fostering transdisciplinary efforts spanning Institutes, Centers, and levels of analysis.