How can doctors create bridges for patients struggling with the 'intention-behaviour gap'?

The healthcare environment is littered with examples of people intending to take action to improve their health but then failing to do so. Consider the unprecedented and prohibitively costly global rise in chronic diseases such as diabetes, cardiovascular disease and obesity, all closely linked to unhealthy lifestyle habits.

It's widely researched and documented that practicing good stress and sleep management, regular physical activity, eating healthy food in moderation, quitting smoking and so on, are good habits to engrain. If these facts are not under dispute, why do so many of us feel like we are in a perennial battle with ourselves when it comes to healthy lifestyle choices? And, most importantly, is there anything we can do about this?

Why does the 'intention-behaviour gap' exist?

Studies show that in the United States, for example, 68% of smokers want to quit and 66% of obese adults want to lose weight. However, the sad reality is that less than 50% of all intended health behaviours are realised.

Intention has long been considered a key predictor of behaviour. So why is it that there can be such a substantial gap between what people intend to do and what they do? This so-called 'intention-behaviour gap', is a divide fed by several barriers to achieving meaningful health improvements:

• Human preferences are irrational, dynamically inconsistent and predictably biased. Traditional economic theories suggest that we make decisions by weighing up costs and benefits and choosing the path that delivers the greatest value. However, boundless rationality and resolute willpower do not accord with human reality. Instead, behavioural economists have shown, for example, that we sharply discount the future relative to the present. In placing greater weight on short-term payoffs, we succumb to the immediate gratification of, say, eating a dessert today and deferring the decision to eat healthily to tomorrow. However, tomorrow we give in to the same temptation.
• Short-term costs can get in the way of starting new healthy behaviours. Delaying gratification means rejecting immediate gains or short-term benefits in favour of bigger, more distant rewards. While the future benefits of daily exercise may be clear, they cost us the immediate gratification or pleasure of spending our exercise time on other activities.
• In a resource-limited environment, differing priorities continually compete for our time, money, attention and cognitive and physical effort. So, fitting in regular exercise competes with family time, work demands, relaxation time and more. And, in environments of severe scarcity, especially where there is poverty, this phenomenon is even more pronounced.
• Prospective memory refers to how well we will remember to carry out actions that are planned for the near future, which happens after a delay or interruption. We rely on prospective memory to remember to regularly take medicines, schedule follow-up doctors' appointments, etc. Ageing causes prospective memory to deteriorate. And, people with chronic diseases often struggle to remember what they should be doing as uncertainty, delays, interruptions, and stressful situations - all common when dealing with illness and healthcare systems - make us prone to memory errors.
• Autonomy and competence are critical to self-regulation. People who are autonomously or intrinsically motivated are more engaged, persistent, and effective than those whose motivations are external and controlled by others. So, where an activity or a strict dietary plan is externally enforced, or where a patient lacks confidence that they can master a task, their motivation and the likelihood of achieving the desired outcome are likely to be low.
• Health and health improvement, are perceived to have high value, but can be abstract notions. Psychological distance leads to thinking that 'action can wait for another day'. Also, where a person struggles to determine that their health has improved, they feel less connected to a future, healthy outcome, lowering the probability that they will act in the present. That's also why action towards healthy choices is highly prone to procrastination.

What sort of strategies overcome the 'intention-behaviour gap'?

Research into all of the disheartening factors that derail our best efforts has fortunately also led to substantive evidence around techniques that overcome the intention-behaviour gap.

Using a 'goal-pursuit' framework, failure to act in a way that promotes health is attributed to:

• A problem with goal-setting - when we're deciding to pursue a specific health goal or action
• Or a problem with goal-striving - when we're following through on a chosen goal

The current thinking is that there's great potential for changing behaviour and improving health outcomes if we can support individuals during the goal-striving phase. What sort of support has the greatest impact?

The power of up-front, well-timed incentives

Upfront, correctly-timed incentives can help to overcome present-bias or inertia in making healthy lifestyle changes and keep a focus on reaching future goals. If structured correctly, they can also help to form long-term habits and we know that once a behaviour becomes a stable habit, it's less likely to be derailed by competing priorities. Lastly, being able to see progress towards a goal, heightens the sense that a goal is within our reach, increasing the tendency to achieve it.

A good example of all of this is in the design of the Vitality Active Rewards (VAR) programme, which rewards members in various ways for achieving both their weekly and long-term, personalised and progressive fitness goals. It's all visualised through an in-app journey. The success of the programme has allowed for a recent spin-off version of VAR that will, from August 2019, become available to all members of the Discovery Health Medical Scheme who are at risk of, or have been diagnosed with diabetes, hypertension and/or hyperlipidaemia - regardless of whether they are Vitality members, and without any cost to them. These members will be rewarded for healthy behaviours that meet their personal health needs and lower their risk - from completing important health checks, adhering to prescribed medicines, buying healthy food and, where applicable, reaching weight-reduction goals. Alerts and reminders will assist members to remember what they need to do, overcoming prospective memory challenges. Healthcare practitioners will be able to encourage patients to participate and view their progress on the Discovery HealthID electronic health record.

Also, the Vitality Active Rewards for Doctors programme (VARD), launched in 2016, helps doctors to get healthier, rewarding them for achieving personalised physical activity goals in the short- and long-term. Doctors who are members of VARD are also ranked on the quarterly VARD leaderboards, where they compete to become VARD 'Top' and 'Most Improved' performers with highest performing quarterly achievers winning substantial prizes.

The power of autonomy and shared decision-making

Healthcare practitioners play a fundamental role in a patient's goal-striving phase. By communicating health information and encouraging shared-decision making, they push patients to define personal health goals and make specific plans around achieving them. Once personal goals have been chosen, a simple technique - 'creating an implementation intention' i.e. making a plan - makes it more likely that patients will follow through required actions.

Patient check-lists, used during consultations, are another useful tool for shared decision-making, encouraging autonomy, engagement, responsibility, and reducing patient forgetfulness. They can cue discussion around medicine side-effects and alternative treatments, disease-specific education, and lifestyle changes needed.

Then, using an 'if-then' framework helps by pairing a desired behaviour with a situational cue. For example, "If I am having dinner at a restaurant and am offered dessert, I will say I only want coffee" or "If I have not exercised by lunchtime on Sunday, I will take the dog for a walk as soon as I have washed the dishes". By helping patients to visualise being in a situation before it happens, doctors help them to act automatically and these responses are less likely to be derailed by competing priorities. Implementation intentions also make goals more real, reducing procrastination and forgetfulness.

Cardio Care and Diabetes Care: Discovery Health's care programmes address the intention-behaviour gap for chronic members

It takes time to facilitate shared decision-making and implement planning. That's why patients enrolled on Discovery Health's care programmes - Diabetes Care, Cardio Care, HIV Care, and Mental Care - see Premier Plus GPs being reimbursed for spending more time with these patients and providing them with the extra support required to effectively overcome barriers to behaviour change in managing chronic illness.

Digital healthcare tools form a distinct part of the ecosystem that surrounds these members. A recent extension of the Diabetes Care Programme has been the introduction of support through telephonic diabetes coaching. It's offered by experienced diabetic educators who are trained in motivational interviewing and other tools that facilitate behaviour change and aims to help patients to execute the treatment plan prescribed by their doctor. In essence, we're helping members identifying intention-behaviour gaps in managing their diabetes and putting plans in place to overcome these barriers. This virtual coaching reduces the challenges of competing priorities, lack of autonomy and low competence by increasing patients' sense of planning and self-efficacy.

Today's doctors

Changing entrenched, undesirable behaviour will always be complex. Never has the role of the healthcare practitioner been more important. By encouraging patients to participate in programmes founded in behavioural science, like Vitality Active Rewards, and spending time helping patients in shared decision-making and developing action plans will go a long way to empowering patients to regain and sustain their quality of life.