Strategies of Health Promotion Unit 4 Article Review

Digitally Characterizing the Dynamics of Multiple Health Behavior Change

Bonnie Spring1, Tammy K. Stump1, Samuel L. Battalio1, H. Gene McFadden1, Angela Fidler Pfammatter1, Nabil Alshurafa1, and Donald Hedeker2

1 Department of Preventive Medicine, Northwestern University Feinberg School of Medicine 2 Department of Public Health Sciences, University of Chicago

Objective: We applied the ORBIT model to digitally define dynamic treatment pathways whereby intervention improves multiple risk behaviors. We hypothesized that effective intervention improves the frequency and consistency of targeted health behaviors and that both correlate with automaticity (habit) and self-efficacy (self-regulation). Method: Study 1: Via location scale mixed modeling we compared effects when hybrid mobile intervention did versus did not target each behavior in the Make Better Choices 1 (MBC1) trial (n � 204). Participants had all of four risk behaviors: low moderate-vigorous physical activity (MVPA) and fruit and vegetable consumption (FV), and high saturated fat (FAT) and sedentary leisure screen time (SED). Models estimated the mean (location), between-subjects variance, and within-subject variance (scale). Results: Treatment by time interactions showed that location increased for MVPA and FV (Bs � 1.68, .61; ps � .001) and decreased for SED and FAT (Bs � �2. 01, �.07; ps � .05) more when treatments targeted the behavior. Within-subject variance modeling revealed group by time interactions for scale (taus � �.19, �.75, �.17, �.11; ps � .001), indicating that all behaviors grew more consistent when targeted. Method: Study 2: In the MBC2 trial (n � 212) we examined correlations between location, scale, self-efficacy, and automaticity for the three targeted behaviors. Results: For SED, higher scale (less consistency) but not location correlated with lower self-efficacy (r � �.22, p � .014) and automaticity (r � �.23, p � .013). For FV and MVPA, higher location, but not scale, correlated with higher self-efficacy (rs � .38, .34, ps � .001) and greater automaticity (rs � .46, .42, ps � .001). Conclusions: Location scale mixed modeling suggests that both habit and self-regulation changes probably accompany acquisition of complex diet and activity behaviors.

Keywords: health promotion, location-scale model, mobile health, multiple health behavior change, self-regulation

Poor-quality diet and physical inactivity are the most prevalent risk factors for chronic diseases, including diabetes, cardiovascular disease, and cancers (Adams et al., 2017; Arena et al., 2015; Bauer et al., 2014; Baruth et al., 2011; Lloyd-Jones et al., 2010; Mendis et al., 2015; Mozaffarian et al., 2015; Myint et al., 2009; Schuit et al., 2002; Spring et al., 2014; Spring et al., 2013). In turn, chronic diseases are the main causes of premature death and disability and the leading drivers of the United States’ $3.3 trillion annual health care costs (Centers for Disease Control & Prevention, 2019). Just 1 in 10 U.S. adults consumes the recommended intake of fruits and vegetables (Lee-Kwan et al., 2017), and fewer than one-third meet dietary guidelines to consume less than 10% of calories from

saturated fats (American Heart Association, 2015; Sacks et al., 2017; U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Only about half meet public health recommendations for moderate–vigorous physical activity (MVPA; Centers for Disease Control & Prevention, 2018), and more than 50% exceed two sedentary hours per day watching TV (Fedewa et al., 2015). Moreover, risk behaviors co-occur: the average adult reports at least two, and 25% report three or more (Baruth et al., 2011; Chou, 2008; Meader et al., 2017; Schuit et al., 2002).

Public health guidelines for diet and physical activity advise consumers to accumulate a total amount of a food commodity (e.g., servings/cups of fruits/vegetables) or type of activity (total minutes MVPA) on a regular basis. They also specify how eating and activity behaviors should optimally be distributed over time: for example, whether target levels need to be met daily or weekly to achieve a health benefit (Dunton, 2018; U.S. Department of Health and Human Services, 2018; U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2010, 2015). What neither current guidelines nor behavioral theories specify well is how to design interventions so that they produce the temporal pattern of changes that leads to a sustainable modifica- tion of behavior. As others have noted, existing psychological theory and analytic methods are more adept at characterizing

Bonnie Spring X https://orcid.org/0000-0003-0692-9868 This study was funded by National Heart, Lung, and Blood Institute

Grant HL075451 and by National Institute of Diabetes and Digestive and Kidney Diseases Grant DK108678 to Bonnie Spring. The work was also supported, in part, by National Cancer Institute Grant T32 CA193193 (PI: Bonnie Spring, providing salary support for Tammy K. Stump).

Correspondence concerning this article should be addressed to Bonnie Spring, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 North Lakeshore Drive, Suite 1400, Chicago, IL 60611, United States. Email: [email protected]

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Health Psychology © 2021 American Psychological Association ISSN: 0278-6133 https://doi.org/10.1037/hea0001057

2021, Vol. 40, No. 12, 897–90*8

897

This article was published Online First February 11, 2021.

differences between people than fluctuations within a person over time (Dunton, 2018; Dunton & Atienza, 2009; Riley et al., 2011).

This is an era when digital sensing affords continuous, real-time detection of changes in a person’s behavioral state and surrounding context. New technologies and analytic methods allow us to mea- sure and conceptualize the dynamics of behavior change in ways that can inform our theories and interventions (Riley et al., 2011). Whereas traditional examination of intervention effects has fo- cused on overall changes to the mean level or frequency of a behavior, we can now leverage technological advances to identify more complex behavioral patterns. The problem being addressed is how to identify behavioral features that are evident before the end of treatment and that can successfully predict whether a healthy behavioral change will be maintained after treatment is withdrawn. Later, we elaborate how we plan to draw predictors of maintenance from a broad array of behavioral features (e.g., changes in day-to- day variability, rate of change in variability, responses to “lapses” in behavior). The present study takes a first step toward that goal by characterizing patterns of change in daily variability (scale) and level (location) of targeted behaviors within a successful interven- tion.

This article’s premise is that breakthrough advances for com- plex health behavior change interventions will be facilitated by introducing more dynamic concepts and tools into two domains of the science of behavior change. The first needed development is an expansion of the manner in which traditional statistical methods characterize within-person change. The second is integration into psychological theory of dynamic constructs that explain how an intervention induces a pattern of transitions between psychological and behavioral states that leads to the acquisition of durable behavioral change. When stated dynamically in algorithmic form, adaptive treatment decision rules (Murphy, 2005) can specify how change in the patient’s response pattern and change in the inter- vention should come to reciprocally determine each other over time (Bandura, 1985).

Intervention Development Model—Orbit Phase 1

Step 1 in the ORBIT treatment development model (Czajkowski et al., 2015) is to identify a clinically meaningful question. Our question is how to maximize healthy change in multiple diet and physical activity risk behaviors for the least possible resource expenditure. Effective interventions for diet and PA risk behaviors exist but are intensive: involving multiple treatment sessions, each lasting from 10 –90 min (Curry et al., 2014, 2018). Patients (Becker et al., 2017; Jensen et al., 2012) and payers (Arterburn et al., 2008; Jones et al., 2015) consistently name high cost and burden (long treatment duration, high time commitment) as top barriers to uptake of intensive behavioral treatments. Yet, even after intensive lifestyle intervention, behavioral improvements of- ten are not maintained (Arterburn et al., 2008; Perri, 1998), prompting recourse to the most common maintenance strategy: continuing to offer behavioral treatment (Perri, 1998), which fur- ther augments cost and participant burden.

Accordingly, a critical goal for the science of health behavior change is to detect when, during treatment, an intervention has produced durable behavioral improvement that might indicate when intervention delivery can begin to be tapered and then discontinued. Likewise, an ability to detect during the posttreat-

ment maintenance phase when a previously stable healthy behav- ior pattern is beginning to “wobble,” could indicate, just in time, when intervention should be reinstated. Such knowledge would allow treatment dosing decisions to be made by assessing dynamic processes that underlie the acquisition and maintenance of durable healthy eating and PA patterns.

Our specific intervention development goal is to optimize the existing Make Better Choices (MBC) intervention for multiple diet and physical activity change (Spring et al., 2012, 2018) to achieve and maintain the maximal healthy behavior improvement that is attainable for the least resource utilization (cf., Spring et al., 2020). All of the work shown here represents activity undertaken in either Orbit Phase 1a (Define: during which the scientific foundation of the behavioral treatment is defined), or ORBIT Phase 1b (Refine: when candidate targets for treatment components are specified and the hypothesized pathway by which treatment produces benefit is formulated; Czajkowski et al., 2015). Our Phase 1 treatment de- velopment process involves performing secondary analysis of two prior MBC clinical trials (Spring et al., 2012, 2018). In ORBIT Phase 1a, we use these data to define what it means to achieve healthful behavior change. We apply location-scale modeling to identify two behavioral features (level and temporal consistency) that change as different interventions produce acquisition of guidelines-concordant diet and activity behaviors. These second- ary analyses were prompted by the premise that the acquisition of healthy behavior change is more likely to be durable when inter- vention causes the behavior to both reach its targeted level and be enacted consistently. In Phase 1b, we sought to refine our under- standing of this behavior change patterning by learning how what is measured as changes in behavioral level and consistency fits into the nomological network of psychological constructs (Cronbach & Meehl, 1955) that are thought to explain the successful acquisition of sustained healthy behavior change. Two constructs in this network pertain to the acquisition of self-regulation skills and the acquisition of habits. For behavioral consistency to be useful as a new construct, it should converge with these related constructs but not overlap entirely.

Orbit Phase 1A: Acquisition of Behavioral Consistency

In this phase, we perform secondary analysis of prior clinical trial data to define what it means to achieve multiple health behavior change. We proposed in the introductory section of this article that boosting the growth of dynamic behavior change in- terventions requires expanding the manner in which traditional statistical methods measure within-person change. Most treatment evaluations have inferred healthy habit acquisition from changes in the frequency or rate of a behavior: increases for healthy behaviors and decreases for unhealthy ones. Many statistical analysis tech- niques for intensive longitudinal data are well-suited to model this type of improvement in behavioral rate. In contrast, another aspect of intraindividual change (improvement in behavioral consistency) has not been measured routinely. Yet, for many medical and public health guidelines, maintaining a stable homeostatic range of a biomarker or behavior is at least as important as attaining a mean target level (American Diabetes Association, 2020; Dunton, 2018; Riley et al., 2011). Consider, for example, two individuals with diabetes and acute coronary syndrome who have the same average blood glucose levels across the month, one whose glucose is within

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898 SPRING ET AL.

a healthy range on most days and the other whose glucose fluctuates between healthy, hyperglycemic, and hypoglycemic. Fewer adverse cardiac events are expected for the patient who maintains a stable glucose level than the one whose glucose shows great within- person variability (Gerbaud et al., 2019). Thus, we sought an analytic technique that could measure within-person variability to study how it is impacted by behavioral intervention. Such an analytic technique could, for instance, let us differentiate interven- tions and individuals that not only improve fruit and vegetable consumption to a targeted level on average but also improve consumption to a similar, high level of fruits and vegetables on most days.

Mixed-effects location scale modeling (a statistical analysis technique for intensive longitudinal data; Hedeker et al., 2008, 2012) appeared to offer the needed capabilities. Location scale modeling quantifies change in within-person variability of behav- ior (scale), unlike most analytic techniques which only assess changes in absolute level (location). The availability of this method let us evaluate the hypothesis that effective interventions produce both improvement in location (increases for healthy be- haviors; decreases for unhealthy ones) and decrease in scale (i.e., increased behavioral consistency) of targeted behaviors. We stud- ied this by applying location scale modeling to data from a previ- ously published trial of behavioral interventions to improve mul- tiple diet and PA behaviors (Spring et al., 2010, 2012).

The Make Better Choices 1 Trial

The MBC1 study enrolled 204 adults with unhealthy levels of sedentary leisure screen time (SED), fruit/vegetable intake (FV), saturated fat intake (FAT), and moderate vigorous physical activity (MVPA). All participants had all four risk behaviors and were randomized to one of four hybrid interventions involving an app plus remote coaching: (a) increase FV and MVPA, (b) decrease FAT and SED, (c) decrease FAT and increase MVPA, (d) increase FV and decrease SED (Spring et al., 2010, 2012). The aim was to determine which combination of one diet and one PA intervention target produced the maximum improvement in all four risk behav- iors. Based on behavioral choice theory (Bickel & Vuchinich, 2000), we hypothesized that the increase FV and decrease SED intervention condition would yield maximum improvement in a composite measure combining all four behaviors because of sub- stitute and complementary relationships between FV, SED, and the other behaviors. Specifically, we predicted and found that in addition to directly increasing FV, this intervention indirectly decreased FAT: FV partially substituted for (crowded out) FAT, probably as a result of increased satiety owing to heightened fiber intake. We also observed a complementary relationship between SED and FAT, such that decreasing leisure screen time was accompanied by decreased FAT, at least partially because reducing TV viewing also decreased the hand-to-mouth snacking with which participants paired it. By the end of treatment, the group that was asked to increase FV and decrease SED improved on a standardized composite score reflecting all behaviors more than the groups in other treatment conditions that were asked to change different pairs of diet and PA behaviors (p � .001), and the difference was maintained through the 6-month follow-up period (Spring et al., 2012).

Method

All participants were asked to wear an accelerometer and use a custom-designed app to self-monitor dietary intake, MVPA, and SED daily during a 2-week Baseline phase, early phase treatment [Rx1: 1 week] when goals were set to 50% of final level, and later phase treatment [Rx2: 2 weeks] when goals were set to 100%. The intervention for all participants included three weeks of telephone coaching as well as a mobile application designed based on Con- trol Systems Theory (Carver & Scheier, 1982) to help participants set diet and PA goals, self-monitor their behavior and receive feedback about progress, and earn financial incentives for self- monitoring and goal attainment. In the 6-month follow-up phase, participants were only incentivized to self-monitor on the follow- ing schedule: daily for one week at week 4, 3 consecutive days for weeks 5 and 6, biweekly for 6 weeks, and monthly until 6-month follow-up. Goal attainment was no longer incentivized. Study procedures were approved by the Institutional Review Boards at the University of Illinois at Chicago and Northwestern University.

Analyses were run separately for each of the four behaviors, with participants divided into one of two groups (Targeted or Not Targeted) with regard to whether their assigned intervention tar- geted that behavior or targeted other behaviors. For instance, for analysis of FV, the Targeted group included those in the increase FV and increase MVPA intervention condition as well as those in the increase FV and decrease SED condition. For FAT, the Tar- geted group included those in the decrease FAT and SED inter- vention condition, and those in the decrease FAT, increase MVPA condition. For MVPA, the Targeted group included those in the increase FV and MVPA intervention condition, and those in the decrease FAT increase MVPA condition. For SED, the Targeted group included those in the decrease FAT and SED intervention condition, and those in the increase FV and decrease SED condi- tion. Here we tested the hypothesis that each behavior would show an interaction between treatment group and time, such that im- provement in the behavior’s rate and consistency would be greater for the group whose intervention targeted that behavior than for those for whom the behavior was not targeted, demonstrating treatment differentiation for the enactment of specific diet and PA behavioral improvements.

Each of the four behavioral outcomes was analyzed using a mixed-effects location scale model, as implemented in the MIXREGLS software program (Hedeker & Nordgren, 2013). To better satisfy the normality assumption of the model, a square root transformation was used for the count outcomes: fruit and vege- table consumption (FV; servings), MVPA (minutes), sedentary leisure behavior (SED; minutes), and arc sin transformation was used for the percentage outcome (FAT; % daily calories attribut- able to saturated fat). The mean, BS variance, and WS variance models included terms for group (0/1), time (0 � baseline, 1 � Rx1, 2 � Rx2) and group by time interaction. The mean model corresponds to a regression model, whereas the variance models (BS and WS) are log-linear regression models so that the resulting variances are always positive (Hedeker et al., 2008). Group was dummy-coded separately for the four outcomes, such that group � 1 for participants in the conditions that targeted that outcome. For example, in the analysis of MVPA, group � 1 for those in the conditions that were targeted to increase MVPA, and 0 otherwise. For SED, group � 1 for the conditions that were targeted to

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899DYNAMICS OF DIGITAL MULTIPLE BEHAVIOR CHANGE

decrease sedentary behavior, and 0 otherwise. For FV, group � 1 for the conditions that were targeted to increase FV, and 0 other- wise. For FAT, group � 1 for the conditions that were targeted to decrease saturated fat consumption, and zero otherwise. With this coding of the outcomes, the main effect of group represents the group difference at baseline, the time effect represents the time trend for the group � 0 (i.e., not targeted) conditions, and the group by time interaction represents the difference in the time trend for the group � 1 (i.e., targeted) conditions, relative to group � 0 condition. Thus, the group by time interaction is of greatest interest here, as it indicates the effect of targeting behav- iors on the outcomes across the time intervals.

Results

For MVPA (see Figure 1), there were significant effects of time (� � 0.25, p � .008) and the group by time interaction (� � 1.68, p � .001) in the mean model. This indicates that all subjects increased MVPA levels across the three time intervals (baseline, Rx1, Rx2), but that the conditions that were designed to target increasing MVPA did so to a much greater degree (cf. Figure 1). In terms of the BS variance modeling, there was a significant effect of time (� � .22, p � .001), indicating that subjects became more heterogeneous across the three time intervals. For the WS variance modeling, there was only a significant group by time interaction (� � �0.19, p � .001). This indicates that the consistency of MVPA within subjects did not change across days for the condi- tions in which MVPA was not targeted, but MVPA became more consistent for the conditions in which it was targeted (i.e., the WS variance was reduced across the time intervals for the targeted MVPA conditions). Exponentiating this estimate yields a variance ratio effect of exp (�0.19) � 0.83. This indicates that the WS variance was reduced by 17% (100% � 83% � 17%), such that the level of PA became more consistent with each successive time interval after baseline for the targeted MVPA group, relative to the group for which MVPA was not targeted.

Similar findings were also observed for the other three behav- iors, such that the mean level of targeted healthy behaviors (FV) increased over time and the mean level of targeted unhealthy behaviors (SED and FAT) decreased over time. In the conditions in which they were targeted, behaviors also became more consis- tent over time. Table 1 presents results for the location scale mixed models run separately for each behavioral outcome, in terms of the

effects on the location (mean) and scale (WS variance). As pre- dicted, these results revealed increases in mean levels of targeted healthy behaviors (PA and FV), decreases in mean levels of targeted unhealthy behaviors (SED and FAT; i.e., improved loca- tion), and decreases in WS variance (i.e., increased consistency, improved scale) for all targeted behaviors.

Discussion

These findings provide preliminary support for the use of loca- tion scale mixed modeling to evaluate improved behavioral fre- quency and increased consistency during the acquisition of healthy diet and activity changes induced by an effective intervention. It is noteworthy that both location and scale improved for each of the quite different health behaviors that the interventions targeted. Location improvements characterized both increasing behavioral levels for low-rate healthy behaviors (FV, MVPA) and decreasing behavioral levels for high-rate unhealthy ones (FAT, SED). Re- gardless of the directionality of the targeted behavior change, interventions that effectively improved the behavior’s location also lowered its scale, diminishing within-person variability across time. Stated differently, effective interventions that achieved guidelines-recommended levels of dietary intake or PA also achieved guidelines-recommended consistency of the behavior across occasions (i.e., in this case, days). It might be asked why we consider consistent nonaction or minimal action for an unhealthy behavior to be a good thing, once effective intervention has re- duced behavioral rate (location) to low or zero. It is because, just as single or rare slips to an unhealthy behavior increase the odds of a full relapse, continued, consistent lapse-free intervals build self- efficacy that is protective against relapse (Kirchner et al., 2012; Larimer et al., 1999). In sum, the introduction of location-scale modeling illustrates the first scientific development that we found needed to support more dynamic behavioral interventions: im- proved modeling of within-person change.

ORBIT Phase 1B: How Is Behavioral Consistency Related to Psychological Constructs Thought to

Underlie Healthful Behavior Change?

The second scientific development that we found needed is the integration into psychological theory of dynamic constructs that explain how a pattern of transitions between psychological and

Figure 1 Changes in mean and WS variance for square root transformed minutes of MVPA over time between groups whose intervention targeted vs. did not target increasing MVPA

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900 SPRING ET AL.

behavioral states could lead to the acquisition of behavioral changes (particularly those that might be maintained). In this instance, we reanalyze prior clinical trial data to learn whether changes to the absolute level and consistency of various diet and PA behaviors co-occur with changes to psychological variables previously identified as important accompaniments of behavior change. When behavioral consistency emerges, does self- regulation improve? Do habits form and strengthen? Both? In other words, we refine understanding of the MBC intervention’s treatment pathway by identifying which psychological variables are associated with improved behavioral level and consistency. In doing so, we sought to provide evidence for behavioral consiste- ncy’s recognition as a distinct construct and to explore its place- ment within the nomological network of related constructs (Cron- bach & Meehl, 1955).

Two main classes of psychological theory are especially rele- vant to achieving changes to healthy behavior that become con- sistently enacted at the daily level: self-regulation theory (Bandura, 1991; Baumeister et al., 2007; Kanfer & Goldstein, 1991) and habit theory (Aarts & Dijksterhuis, 2000; Gardner, 2015). Self- regulation is the process of volitionally exerting control over the self, by inhibiting competing responses, to change or sustain a pattern of thought, feeling, or behavior (Baumeister et al., 1994). An intervention to improve self-regulation might teach skills to execute generalizable behavior change strategies or techniques that have utility across many different risk behaviors and contexts. Such behavior change techniques (BCTs) have been characterized in comprehensive taxonomies put forward by Michie and col- leagues (Abraham & Michie, 2008; Michie et al., 2011, 2013). Our recent metareview of meta-analyses examining interventions to foster diet and physical activity changes for health or weight loss found that goal-setting and self-monitoring were by far the most commonly evaluated BCTs (Spring, 2019). None of the specific 14 BCTs analyzed was consistently related to diet and activity improvements, however (Spring, 2019). On the other hand, in multiple studies, increased self-efficacy has been a consistently observed consequence of effective interventions that train self- regulatory skills. Self-efficacy often mediates the beneficial effects of self-regulatory interventions on diet and PA behavioral out- comes (Schneider et al., 2016; Darker et al., 2010). Hence, we

consider greater self-efficacy to be an indicator of better self- regulation.

Self-regulation is a goal-driven and effortful undertaking, particu- larly when it involves pursuit of multiple different behavior change goals that require complex new action patterns. Given the consider- able burden of executing several System 2 deliberative, conscious, goal-directed cognitive processes at once (Hagger & Chatzisaran- tis, 2016; Kahneman, 2011), it would be helpful if intervention could be designed to reduce the burden of multiple behavior change. One possible avenue is to repeat targeted behaviors suf- ficiently often in the presence of a consistent context that the actions become habits. Habits are cue-driven, triggered automati- cally by contextual stimuli, undergirded by System 1 automatic processes, no longer requiring conscious effort to initiate (Kahne- man, 2011; Lally et al., 2008; Lally & Gardner, 2013). When life demands are high, being able to rely on habitual responding frees up cognitive resources to address other challenges that require deliberation and reflection (Neal et al., 2013).

Consistency has slightly different meanings and is operational- ized differently when framed from the vantage point of habit theory versus self-regulation theory. As noted above, the appeal of self-regulatory strategies or BCTs is that they are generalizable: consistently executable and effective across contexts that are vari- able or changing. In that respect, temporal self-regulatory consis- tency maps well onto public health guidance that prescribes per- forming a behavior daily or weekly regardless of whether the person is in usual surroundings or in a radically different time zone or continent with different cues. Self-regulatory consistency that causes a behavior to be repeated regularly over time regardless of context is thought to be achieved deliberatively by the imposition of goal striving

The premise that consistency (scale) is also a marker of habit acquisition emerged from animal models of stimulus-response (S-R) learning, whereby stimuli (e.g., light, tone) were thought to “hijack” control of an associated conditioned response, rendering actions predictable (Skinner, 1953; Watson, 1925). For humans, the stimuli thought to hijack responding and induce consistency are cues such as an environmental trigger, time of day, or imme- diate prior action. Also generalized from animals to humans is frequency (location), the other longstanding habit acquisition marker. As stimulus–response pairings are learned, behaviors are thought to become produced, changing in rate (frequency) as the number of cue exposures increase or decrease. In humans, the initial phase of habit learning is thought to rely on goals, motives, and rewards. As responding becomes habitual, those influences are posited to diminish. The behavior becomes automatically triggered by contextual cues (Kwasnicka et al., 2016; Lally & Gardner, 2013; Wood, 2017), although some influence of rewards and goals may persist (Aarts & Dijksterhuis, 2000; Phillips, 2019). Hence consistency, from the perspective of habit theory, means that specific physical or psychological contextual cues reliably trigger specific behavioral responses. For example, location-scale model- ing has been applied to test whether negative mood consistently cues cigarette smoking, on the one hand, and, on the other hand, whether smoking consistently triggers improved mood (Hedeker et al., 2008).

One set of signs that behavioral control has changed from deliberative (effortful and difficult to sustain) to habitual (auto- matic and persistent) is that responding speeds up and mental

Table 1 Results of Location Scale Models Run Separately for Each Behavioral Outcome

Model MVPA FV SED FAT

Mean (location) model Intercept (�) 5.28��� .80��� 13.37��� 3.29���

Time (�) .25��� .11��� �.68��� �.18���

Group (�) .30 .12� �.31 �.08�

Group � Time (�) 1.68��� .61��� �2.01��� �.07�

WS variance (scale) model Intercept (tau) 3.06��� �.53��� 3.30��� �.74���

Time (tau) �.03 .01 �.13��� �.002 Group (tau) .10 .18� �.03 .03 Group � Time (tau) �.19��� �.75��� �.17��� �.11���

Note. MVPA � minutes of moderate–vigorous physical activity; FV � fruit and vegetable servings; SED � minutes of sedentary leisure screen time; FAT � percent of calories consumed from saturated fat. � p � .05. ��� p � .001.

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901DYNAMICS OF DIGITAL MULTIPLE BEHAVIOR CHANGE

effort reportedly decreases (Schneider & Shiffrin, 1977; Shiffrin & Schneider, 1977). Another is that different brain neural circuitry becomes activated. Whereas initial learning activates a network that links motor regions (basal ganglia, caudate) with the midbrain and prefrontal cortex (associated with self-control and planning), continued performance shifts activation to a neural network con- necting the putamen of the basal ganglia with the sensorimotor cortices and parts of the midbrain (Knowlton & Patterson, 2016; Tricomi et al., 2009; Yin & Knowlton, 2006). Hence, responding appears to transition from being regulated by higher cortical struc- tures to being underpinned by sensorimotor circuits.

Habit theory performs well for understanding the acquisition of uncomplicated behaviors that become conditioned to discrete cues. Debate is ongoing about whether habit formation also can explain the acquisition of more complex health-promoting diet and PA behaviors (Mullan & Novoradovskaya, 2018; Trafimow, 2018). To the extent that habitual responses are defined as those that have become completely cue-driven and free from cognitive influence, it is unlikely that habit alone will suffice to explain the acquisition of complex behaviors. Eating and PA behaviors appear to remain under partial cognitive control, never acquiring full automaticity (Gardner & Lally, 2018; Rhodes & Rebar, 2018), and continuing to need some degree of volitional self-regulation. We note, though, that there are interesting hybrid forms of regulation. For example, when using implementation intentions, a self-regulatory strategy, an individual deliberatively self-administers a cue that she consis- tently pairs with a specific response. By doing so repeatedly, the person functionally administers a stimulus-response conditioning protocol whereby the cue may eventually come to trigger the response automatically.

Habit research has a long history of objectively measuring habit formation. Goal independence, behavioral continuation after with- drawal of reward, altered frequency, and consistency of behaviors are all objective markers of habit formation that trace from animal to human research. Recently, however, habit acquisition has be- come equated with the attainment of subjective automaticity (Kwasnicka et al., 2016; Lally & Gardner, 2013; Wood, 2017), shifting research attention away from overt behavioral measure- ment and toward assessment of subjective experience (Verplanken & Orbell, 2003). The concern that automatic mental processes are, by definition, inaccessible to conscious awareness (Schneider & Shiffrin, 1977; Shiffrin & Schneider, 1977) is mitigated somewhat by the finding that the trajectory of change in automaticity is directly preceded and predicted by the individual’s trajectory of behavioral frequency and consistency (Gardner & Lally, 2018; Lally et al., 2010).

To refine our understanding of the MBC intervention’s treat- ment pathway, we analyzed whether the improved level and con- sistency produced in each diet and PA behavior was associated with greater automaticity (operationalizing habit strength) or greater self-efficacy (operationalizing self-regulation).

The Make Better Choices 2 (MBC2) Trial

The MBC1 trial demonstrated that a multiple behavior change intervention targeting improvements in fruits/vegetables and sed- entary leisure screen time maximized overall healthy change in the two targeted behaviors as well as in saturated fat intake. MVPA did not improve as a tag-along, incidental change, but it did

improve to guideline-recommended levels in other intervention conditions that targeted it directly. These results suggested a need for intervention to target MVPA directly in addition to FV and SED in order to bring about improvement in all four risk behav- iors. On the other hand, there was reason for concern that address- ing three behaviors at once (FV, SED, PA) could prove over- whelming (Schulz et al., 2014; Spring et al., 2004). Hence, the MBC2 trial compared two different versions of the MBC inter- vention to a contact control intervention that addressed stress and sleep. A Simultaneous MBC treatment condition intervened on all of FV, SED, and PA throughout a 12-week intervention period. A Sequential MBC treatment condition targeted FV and SED for the first 6 weeks and added PA for the last 6 weeks. We hypothesized that both Simultaneous and Sequential MBC intervention would improve diet and PA as compared with control and that Sequential would produce greater benefit because its response demands were more manageable. In fact, both Simultaneous and Sequential MBC treatment produced comparably large diet and PA improvements to guideline levels, which were sustained to final follow-up at 9 months (Spring et al., 2018). Of particular relevance here, the MBC2 study assessed both automaticity and self-efficacy for each behavior at the end of the treatment phase. This enabled us to evaluate whether the level or the consistency of each diet and PA behavior was associated with greater habit formation or better self-regulation.

Method

The MBC2 trial enrolled 212 adults, all of whom demonstrated unhealthy levels of SED, FV, FAT, and moderate vigorous phys- ical activity (PA) during a 1-week baseline period of self- monitoring performed using a custom smartphone app and worn accelerometer (Spring et al., 2012). Study procedures were ap- proved by the Institutional Review Board at Northwestern Univer- sity. During a 12-week intervention, participants used the app to set diet and PA goals, self-monitor their eating and PA, receive feedback about progress from the app, and receive remote tele- phone coaching. Goals for the Sequential and Simultaneous inter- vention conditions were tapered until targeted behaviors reached guideline levels. For the Simultaneous condition, goals for all three criterion health behaviors (FV, SED, and MVPA) were tapered to guideline levels from weeks 1 through 6 of the intervention period, after which participants were instructed to maintain goal level performance for the subsequent 6 weeks of the intervention period. For the Sequential condition, FV and SED goals were tapered to guideline levels during weeks 1 through 6, and maintained there- after, whereas MVPA goals were introduced and tapered up to guideline level during weeks 7 through 12. Hence, goals for all three targeted behaviors for both Simultaneous and Sequential conditions had been fully tapered to guideline levels during the last two weeks of treatment (weeks 11 and 12).

The week following the intervention period (week 13) was the first study follow-up assessment period. Participants were in- structed to continue self-monitoring their behaviors during this period, but they received no additional coaching. They also com- pleted self-report questionnaires about perceived automaticity and self-efficacy for each targeted diet and PA behavior (FV, SED, MVPA). Automaticity was assessed using the automaticity sub- scale of the Self-Report Habit Index (SRHI; Verplanken & Orbell,

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2003), which shows good internal consistency (� � .92; Gardner et al., 2012). Self-efficacy was assessed using a measure developed to evaluate self-perceived ability to enact health behavior changes (Marcus et al., 1992). The measure also showed good internal consistency for behaviors targeted by MBC intervention (� � .94 –.96; Schneider et al., 2016). Minor adjustments were made to adapt wording to the specific targeted behaviors (FV, MVPA, and SED).

Our goal was to evaluate associations between location and scale for each targeted behavior with self-efficacy and automatic- ity for that behavior. Hence, we computed location and scale for each behavior during the last 2 weeks of the intervention phase (weeks 11 and 12), when goals for all three criterion behaviors in both diet and PA intervention conditions had been fully tapered to guideline levels. Given their lack of difference, data from the Simultaneous and Sequential MBC intervention conditions were combined for this analyses. Data from the control Stress and Sleep condition were not included in these analyses because that group self-monitored behaviors other than diet and PA during weeks 11 and 12.

Location and scale estimates were computed for each of the three targeted behaviors (FV, SED, MVPA) during the last two weeks of the intervention (weeks 11 and 12) using mixed-effects location scale modeling implemented in the MIXREGLS software program (Hedeker & Nordgren, 2013). Models were run separately for each of the three targeted behaviors (FV, SED, MVPA). As for the MBC1 data, square root transformations were applied to each count outcome (FV servings, SED minutes, MVPA minutes) to better approximate normality. Sex was included as a covariate, dummy coded such that male was the reference group. Bivariate correlations measured the associations between estimates of loca- tion and scale and measures of self-efficacy and automaticity for each behavior. To account for possible interactions between loca- tion and scale in their associations with either self-efficacy or automaticity, we regressed self-efficacy and automaticity for a given behavior onto (a) location, (b) scale, and (c) the interaction between location and scale for that behavior. If the interaction term was significant, we planned to probe it with postestimation anal- yses.

Results

Bivariate correlations between self-reported self-efficacy and automaticity for SED, r � .57, p � .001, FV, r � .59, p � .001, and MVPA, r � .48, p � .001, revealed significant and positive associations with comparably large effect sizes, indicating consid- erable shared variance between self-efficacy and automaticity for each behavior.

For SED, higher scale (more variability, less consistency) was significantly associated with both lower self-efficacy (r � �.22, p � .014) and lower automaticity (r � �.23, p � .013). However, location (amount or level) of SED was not associated with either self-efficacy (r � �.08, p � .409) or automaticity (r � �.15, p � .096). Further, there was no interaction between location and scale in predicting either self-efficacy (Estimate � .17, t � 1.28, p � .20) or automaticity (Estimate � .02, t � 0.08, p � .93). This lack of an interaction indicates that, for SED, the association between greater temporal variability (i.e., scale) of SED with lower self-

efficacy and lower automaticity did not vary based on the total quantity (i.e., location) of sedentary behavior.

For FV and MVPA, scale was not associated with either self- efficacy (FV, r � .06, p � .547; MVPA, r � .02, p � .777) or automaticity (FV, r � .12, p � .200; MVPA, r � �.10, p � .286). On the other hand, for both FV and MVPA, greater location (level) was significantly associated with higher self-efficacy (FV, r � .38, p � .001; MVPA, r � .34, p � .001) and greater automaticity (FV, r � .46, p � .001; MVPA, r � .42, p � .001). Again, there was no evidence of an interaction between location and scale in pre- dicting self-efficacy (FV, p � .737; MVPA, p � .820) or auto- maticity (FV, p � .402; MVPA, p � .878). This lack of interac- tions indicates that the positive relationship between the amount (i.e., location) of each behavior and increased self-efficacy and automaticity for the same behavior, did not vary based on how consistently the behaviors were enacted.

Discussion

These results from the MBC2 trial indicate that self-regulatory strength and habit strength are strongly positively correlated for the complex diet and physical activity changes we studied. The findings suggest that the acquisition of complex diet and physical activity behaviors probably rests on both good self-regulatory skills and strong habits. Notably, specific diet and physical activity risk behaviors differed in whether it was their improved level or their improved consistency as a result of behavioral intervention that correlated with greater self-efficacy and automaticity. For both healthy behaviors that occurred at a low level initially (FV, MVPA), it was progressing to perform a greater amount of the behavior that correlated with greater feelings of self-efficacy and automaticity. In contrast, for the unhealthy behavior, sedentary leisure screen time, which occurred at too high a level initially, it was improving the consistency of time spent on the behavior across days that correlated with increased self-efficacy and auto- maticity. We note that because this measure of consistency was taken at the end of the intervention period, when behavioral improvements had largely been accomplished, low scale meant being consistent across days in practicing a lower level of the behavior (which was mostly TV viewing) than had been practiced at baseline.

Conclusions

The overarching goal of this research is to optimize a behavioral intervention to improve multiple diet and physical activity risk behaviors in a sustainable, resource-efficient way. This article illustrates the application of Phase 1 of the ORBIT model with the goal of understanding and refining the important intervention targets and outcomes in a multiple diet and physical activity intervention.

In Orbit Phase 1a, we sought statistical analysis techniques that could operationalize and quantify improvement in behavioral fre- quency and consistency using dense digital data obtained from mobile tools. Having identified mixed location scale modeling as a method of intensive longitudinal analysis that meets our needs, we conducted secondary analyses of data from a previously pub- lished study. In the MBC1 study, participants utilized an app, telephone coaching, and incentives to achieve targeted goals for

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pairs of four unhealthy diet and physical activity risk behaviors, all of which characterized them at the study’s outset. As hypothe- sized, results showed that targeting each specific behavior via behavioral intervention improved its frequency and consistency over time to a greater extent than behaviors not targeted by the intervention. The findings suggest that the induction of improved behavioral location as well as decreased scale (increased consis- tency) hold promise as a dynamic behavioral phenotype for diet and physical activity improvement. Particularly if future research shows that improved location and decreased scale reflect a pattern of behavioral acquisition that has potential to be sustainable, then the consistency of a behavior as well as its level may both become intervention targets.

In Orbit Phase 1b, we consulted prior research literature to identify candidate treatment pathways through which behavioral intervention could produce potentially sustainable improvements in diet and physical activity behaviors. We identified relevant constructs from two bodies of psychological science: one charac- terizing self-regulation and one characterizing habit acquisition. Habitual responses triggered by a stable contextual cue have the advantage of proceeding automatically without effort, freeing up mental capacity to devote to more effortful deliberative processing. Self-regulation requires more burdensome, effortful processing, but offers the advantage of enabling complex diet and activity patterns behaviors to be executed appropriately across variable contexts. Both self-regulatory skills and habit strength tended to covary for each improved behavior, suggesting that both may undergird successful performance. Interestingly it was an increase in the level of behaviors that began at a low rate that correlated with greater feelings of self-efficacy and automaticity about the behavior, as if the challenge of initiating change in these behaviors primarily involved building up a large stimulus-response repertoire by which to increase the behavior’s frequency. On the other hand, it was the consistency of suppressing an unhealthy behavior that covaried with feelings of self-efficacy and automaticity about it, as if relentless inhibitory control was the pathway to success in improving such behaviors.

A novel contribution of this work has been to introduce the concept of behaviorally consistent improvement as a potential dynamic operational definition of the acquisition of a complex behavioral pattern. An understanding of how treatment influ- ences behavioral dynamics would have implications for how interventions could be designed and delivered in ways that minimize treatment burden and cost while still maximizing sustained healthy behavior change. For example, the opera- tional definition of behaviorally consistent improvement could serve as a tailoring variable to guide the design of adaptive treatment algorithms (e.g., that remove intervention compo- nents for those who exhibit sustained improvement or add them for those who fail to attain consistent behavioral improvement; Almirall et al., 2014)

We envision a day when algorithms using a rich array of behavioral features, many inferred from digital sensing, will be able to track behavior change and adaptively guide intervention. These developments will be made possible by applying new statistical analysis techniques and machine learning to measure behavioral dynamics in new ways. For example, in addition to measuring an individual’s level of a behavior when an inter- vention starts and its slope of change over time, we can also

statistically analyze how consistently the person displays the behavior at the start and end of the intervention and their rate of change in this variability over time. We can cluster these features in a way that accurately characterizes people who will go on to maintain a healthy behavioral change postintervention versus those who will not. This allows us to apply machine learning methods to derive additional features such as specific ranges of the behavior’s level and consistency during the inter- vention that characterize future maintainers. We can even use the ranges to extract additional features that might predict posttreatment behavioral maintenance, such as the time that it took to first reach the target ranges of mean behavioral level and consistency and the duration of time during the intervention that their behavior remained within the target range. An algo- rithm using this rich array of features might signal, during or at the end of an intervention, which people have improved a targeted behavior in a manner that is durable and unlikely to regress to prior levels following removal of treatment. A similar dynamic treatment algorithm might support time-varying dos- ing decisions based on the real-time detection of behavioral patterning that predicts progression toward durable healthy change. Such advances may allow interventions to become more resource-efficient and scalable because we can tell when an individual has achieved a sustainable pattern of health be- havior improvement that allows intervention to be tapered, and then stopped, with low risk of relapse.

The current work has strengths in introducing a novel appli- cation of location scale mixed modeling to quantify the acqui- sition of consistent behavioral improvements that have the potential to be sustainable. Use of this method was made feasible by the repurposing and de-aggregation of dense digital data collected from mobile health tools, which we had initially averaged over week-long intervals to analyze intervention out- comes. In addition to being resource-efficient, this strategy has enabled us to extract new information about behavioral dynam- ics that was invisible before de-aggregating and analyzing the data via location scale methods.

The current work also has limitations, chief among which is the absence of evidence about whether behaviorally consistent improvement in diet and activity behaviors bears an association with maintenance of behavioral improvements after interven- tion ends. No data on behavioral maintenance were presented here because our Phase 1 activities concern identifying and understanding the dynamic phenotype(s) of behavioral acquisi- tion. Our next step will be to examine whether the features that define the successful acquisition of multiple diet and activity change also define and predict its maintenance. A second lim- itation is that our assessments of diet and physical activity behaviors were based primarily upon self-report. It can be noted that previous studies support the validity of self-report diet and activity assessments administered via a mobile device (Beasley et al., 2005; Clark et al., 2009; Sternfeld et al., 2012). Also, to further encourage honest reporting, in MBC1 we also imple- mented a bogus pipeline protocol whereby participants submit- ted grocery receipts, accelerometer data, and urine samples that they believed would be used to evaluate their self-reports (Ro- ese & Jamieson, 1993). Still, replicating this work using objec- tive sensor data to detect and monitor all behaviors will be an important step forward.

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In sum, this work illustrates the use of the ORBIT model as a supportive framework to guide early phase basic research needed to prepare to optimize an existing behavioral interven- tion. The goal of the intervention will be to initiate, and ulti- mately maintain, the improvement of multiple prevalent chronic disease diet and physical activity risk behaviors in a resource- efficient manner. The promise of this work lies partly in the potential that it may lead toward greater basic science under- standing of dynamic mechanisms that underlie the acquisition of needed complex healthy lifestyle patterns that hold up against the challenge of changing contexts. It also lies in the practical prospect of being able to design adaptive data-based treatment algorithms to guide sound decisions about the mag- nitude and timing of intervention dosing. To fulfill both objec- tives, the next phase of this research program will incorporate optimization designs (cf., Collins et al., 2007; Pfammatter et al., 2019; Spring et al., 2020) that evaluate how to balance inter- vention effectiveness with resource efficiency.

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Received October 1, 2019 Revision received October 21, 2020

Accepted October 26, 2020 �

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Call for Nominations

The Publications and Communications (P&C) Board of the American Psychological Association has opened nominations for the editorships of Emotion, Experimental and Clinical Psychopharma- cology, Journal of Comparative Psychology, Journal of Counseling Psychology, Journal of Experimental Psychology: Applied, Journal of Experimental Psychology: Human Perception and Performance, Journal of Personality and Social Psychology: Attitudes and Social Cognition, Journal of Psychopathology and Clinical Science (formerly Journal of Abnormal Psychology), and Rehabilitation Psychology. Paula R. Pietromonaco, PhD, William W. Stoops, PhD, Dorothy M. Fragaszy, PhD, Dennis M. Kivlighan, Jr., PhD, Daniel G. Morrow, PhD, Isabel Gauthier, PhD, Shinobu Kitayama, PhD, Angus MacDonald III, PhD, and Dawn M. Ehde, PhD, respectively, are the incumbent editors.

Candidates should be members of APA and should be available to start receiving manuscripts in early 2023 to prepare for issues published in 2024. The APA Journals program values equity, diversity, and inclusion and encourages the application of members of all groups, including women, people of color, LGBTQ psychologists, and those with disabilities, as well as candidates across all stages of their careers. Self-nominations are also encouraged

Search chairs have been appointed as follows:

� Emotion, Chair: Richard Petty, PhD � Experimental and Clinical Psychopharmacology, Chair: Mark Sobell, PhD � Journal of Comparative Psychology, Chair: Cheryl Travis, PhD � Journal of Counseling Psychology, Chair: Danny Wedding, PhD � Journal of Experimental Psychology: Applied, Co-Chairs: Kathleen Kendall-Tackett, PhD,

and Mo Wang, PhD � Journal of Experimental Psychology: Human Perception and Performance, Chair: Michael

Roberts, PhD � Journal of Personality and Social Psychology: Attitudes and Social Cognition, Co-Chairs:

Richard Petty, PhD, and Steve Kozlowski, PhD � Journal of Psychopathology and Clinical Science (formerly Journal of Abnormal

Psychology), Chair: Stevan Hobfoll, PhD � Rehabilitation Psychology, Chair: Michael Roberts, PhD

Nominate candidates through APA’s Editor Search website (https://editorsearch.apa.org).

Prepared statements of one page or less in support of a nominee can also be submitted by email to Jen Chase, Journal Services Associate ([email protected]).

Deadline for accepting nominations is Monday, January 10, 2022, after which phase one vetting will begin.