Extending Behavior Change Models

The Example of Healthy Feeding of Children

Summary:
Successful behavior change requires not only changing a single behavior step but building up a sequence of positive behaviors. We demonstrate through the example of feeding children that a chain of behaviors is required, all behavior units in the sequence are required to go right regularly for achieving desired results. A more successful behavior change model provides a pathway through this complex decision making, helping people line up the required behavior units in succession. One way to do that is by providing a tangible vision throughout the process, while emphasizing that the environment we find ourselves in is not designed to facilitate reaching our objective.

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Keywords:
Behavior change, habit change, behavior units, behavior change capacity, chain of behaviors, sequence of positive behaviors, baseline behaviors, habitual neglect of environments and prompts, tangible vision  

Outline:
1.   Complexity, not simplicity, of behavior change
2. Behavior units
3.     Chain of behaviors
4.     Constraints
5.     Layers of objectives
6.     Time horizons
7.     Positive-driver spiral
8.     Tangible vision
9.     Baseline habits
10.  Behavior prompts in the environment
11.  Key areas for further research

Arguments:

1. Complexity, in addition to simplicity of behavior change. A line of inquiry of behavior research posits that successful behavior change requires adjustments to be so small and specific that they can be accomplished in one step. The new behavior, if repeated many times, can then become a habit and the seed of further changes, both through impact on the outcome of our behaviors in total and through learning the pattern of practicing executing change. In the past, advice customarily given to people attempting to change behavior or habits in order to obtain for example better health often seemed to violate this rule. “Eat healthier snacks,” or even “Feed your child broccoli,” are not accomplished in single steps. Rather, to follow such advice just once, one would have to plan and execute a complex series of actions, each one with its own challenges:

1. Explicitly intending on eating or feeding healthier;
2. Planning meals and within that a healthier snack;
3. Knowing the criteria for what makes the new item healthier;
4. Having the healthy option available in the store (or at food vendor);
5. Choosing the healthier item once in the store;
6.     Being able to obtain (pay for) it;
7.     Taking it home;
8.     Storing it properly;
9.     Preparing it for eating;
10.  Serving it, at the right time and place;
11.  And finally eating it.

And in the case of feeding a child:
12.  Having already taught the child how to try new foods previously, so they will consider eating or tasting the new item;
13.  Involving the child in preparation of the meal;
14.  Eating together with the child during an eating (social) event, rather than eating separately and/or multitasking while eating; and
15.  Deciding what food is available when and where but allowing the child to decide whether to eat or not and how much. [[i]]

Clearly, even the seemingly simple objective of eating a healthier snack this one time or feeding your child broccoli can’t be accomplished by just one step but require many.

[i] Satter method of eating competency https://www.ellynsatterinstitute.org/family-meals-focus/21-eating-competence/

2. Behavior units. I call the actions which can be performed and consequently changed in one step, and with one decision, a behavior unit. Performing all required positive behavior units in succession leads to one positive event towards our objective. I ate a healthy snack today or my child ate the broccoli I served for dinner. Performing the required positive behavior units in succession repeatedly over time leads to achieving the objective. Behavior units become habits if they are performed regularly and on autopilot.

3. Chain of behaviors. The desired objectives may look simple and measurable (for example, healthier snacking or X pounds weight loss) but they are actually achievable only by the successful and successive completion of numerous behavior units. If a behavior unit is not performed towards achieving the objective, the chain breaks down and that puts the expected result into jeopardy. Chains can be long and complex; while even a single broken link can result in failure to reach the objective. There may be several different behavior chains leading to the desired result of eating healthier snacks, but the behavior units in the specific chain we have chosen have to all line up.

4. Constraints. Some behavior units are limited by or are defined by constraints outside of the subject’s control. Example: You may want to eat fresh fruit for a snack, but if you can’t obtain it (i.e. in food deserts), that is an outside constraint. Studying the feedback of users of the FYK program, we found that the most often perceived outside constraint for feeding children healthier was cost. However, we also found that perceived constraints can and do change over time.

5. Layers of objectives. The expected result of behavior change, such as feeding one’s child healthier pertains to one single aspect of life, while in fact it is embedded in multiple other aspects. For example, eating or feeding your child healthier is embedded in the financial, social or emotional aspects of one’s life. Each of those other aspects have their own objectives, possibly competing or colliding with the eating healthier objective. Given one’s present constellation of objectives, some behavior units in the chain will work towards achieving a particular objective, while others will serve a different objective and cause this particular behavior chain of feeding our child healthier to break down.

Behavior change can only be interpreted in the context of how our individual objectives are fulfilled by our present behaviors or where they break down and how our environment is changing and thus requires that our behavior to achieve our objectives adjusts. Objectives or our environment changing too fast are conducive to failing in achieving our objectives.

6. Time horizons. The difference between short term and long-term objectives is also of particular interest. In case of feeding children in a healthy way, the short-term interest in having a child eat a reasonably nutritious meal right now is in some conflict with raising a child with high eating competency. For example, pressuring or even encouraging a child to eat a particular meal may seem like a necessary action in the moment but works directly against the long- term objective of teaching the child desiring to eat a variety of food and self-regulating the amount of food they eat.

7. Positive-driver spiral. When one succeeds in changing a single behavior unit, it provides an “Ah-hah” moment, a positive emotion related to the change, which increases personal efficacy and initiates a positive spiral to address the next behavior unit in the chain. This positive emotion (recognized and rejoiced over) is the driver of further forward motion. In feeding children, the most powerful of the “Ah-hah” moments come when the child voluntarily chooses a healthier option (eats a vegetable! of their own volition) or self-regulates (eats one muffin instead of several, because that feels satisfactory for now).

8. Tangible vision. Some behavior change models miss a crucial element: To succeed in knowing what is the next action and perhaps behavior change which is required of us in our particular chain, individuals need to have a tangible vision/idea as to how the successful outcome will look and feel like in practice, which goes beyond having sufficient motivation, perceived connection to the goal, self-efficacy, the skill to change and the prompt to one behavior unit. A tangible vision enables the individual to build up the behavior unit chain. Example: It is not enough to be prompted to and able to buy broccoli in order to eat healthier; one has to be able to visualize and carry out the physical experience of preparing, cooking, serving, tasting and eating broccoli soup, and asserting the identity of being a person who cooks and eats broccoli soup however new that identity is for the individual. In other words there is a direction to the behavior unit chain. If this vision is missing it is not possible for the individual to build the behavior unit chain up without outside help.

 Recognizing this tacitly is why health behavior technology firms went back to providing individual coaching on top of digital assistance programs and apps, and why pediatric obesity treatment programs depend heavily on case coordinators in addition to clinical personnel, doctors, nurses, and dieticians.

9. Baseline habits. I define baseline habits as behavior units that are automatically performed over time, preferred or executed by default.

People develop their baseline habits in different ways, while not always conscious of what they are doing:

a.     Based on what is convenient to do in the present environment
b.     Via behavior explicitly or implicitly learned (conditioned) during childhood from caretakers or shaped by strong cultural or socio-economic influences

Example of strong environmental influence: From the abundant availability of soft drinks in every setting and especially in grocery stores, one may naturally assume that consuming them is a norm, and that that is not overly detrimental to one’s health, even though the ratio of soft drinks to other foods in the store in no way represents the preferred ratio of consuming them in one’s diet.

Example of conditioned influence: Your child notices chips on the shelf in the grocery store and impulsively wants to get some. You now have to either (1) examine the chips, decide if eating it is part of the healthy snack eating objective you have, refuse and explain to your child why you are not buying it even though it is offered right there, or (2) agree to buy it, which breaks your behavior unit chain to reach your objective but stops your child screaming. Over time your clever child concludes that if chips are available in the store, they can be part of their regular diet, even if it requires screaming to get them.

Notice that neither of the above results was by your design.

If I customarily drank soft drinks or ate chips, and especially during childhood, I will most likely want to continue on with this baseline habit, everything else being equal. When my circumstances change, for example if I now face an emerging health problem, I will compare what I need to do to achieve my new objective of stopping the decline of my health to my baseline habits. I will experience a strong sense of hardship when depriving myself of soda or chips, only because they were part of my baseline, whether they got there by design or not. This factor is independent of the possible addictive nature of the product or any withdrawal experience caused by reducing the intake of caffeine, sugar or preservatives. Even if I am forced to reevaluate my actions due to the medical diagnosis of diabetes or heart attack, this changing of behavior can stop or reset to the baseline habit, after the initial fear subsides. Childhood food experiences and the behaviors which a parent models around food are likely to be influential in defining behavior around food and eating.

10. Behavior prompts in the environment. At the risk of stating the obvious, behavior prompts coming from the environment are not optimized for achieving any individual’s desired outcome. For example, the way food production, distribution and marketing create the food landscape is not optimized on the needs of the individual but more directly on the operational interest of producers and distributors. This is also true for information about food. To eat according to a certain health objective in such an environment requires a habitual neglect of the overpowering and on occasion even suspect marketing messages and the immediately gratifying consumption of easily and abundantly available shelf stable, processed and prepared (junk) food and food like items.

To practice this habitual neglect of the environment and its messages requires (1) an awareness of the environment and its quality of optimizing for interests other than that of the individual, and (2) a detailed inner vision of both the end result of what meal will be offered and how to go through the selective process of an entire set of behavior units, the chain of planning in advance, procuring, storing, preparing, serving, and eating in this given environment. Unless one is diagnosed with food allergy, faces the immediate risk of serious physical harm or death, or is under a strong social or cultural influence, very few people are able to develop this habitual neglect of the foodscape on their own.

11. Key areas for further research. We propose that key areas for further research in behavior change models include how to overcome the difficulty in maintaining the attitudes required to perform the chain of behavior units, especially the action sequences where we have to diverge from our baseline habits. How to overcome the lack of tangible vision, to identify what behavior units constitute the required sequence for achieving our short and long-term objectives. It is also of great interest how this can behavior change assistance can be provided at scale. One of the most intriguing aspects of this proposed approach is that this type of behavior change intervention seems to be applicable in differing geographical, cultural and socio-economic environments.