Physical activity has countless benefits for our well-being. One of the biggest (rational) arguments for getting some physical activity is to reduce our risk for cardiovascular diseases (CVDs), which are among the leading causes of poor health worldwide. However, as we all know, following up on our healthy intentions with actual exercise can be (irrationally) hard. This discrepancy between our intentions and our behaviour has been coined the ‘intention-behaviour gap’, and dual-system theories may have a key role in bridging this gap.
In the Action Line 'Prevention' we have set out to evaluate the efficacy of dual-system theory and evidence based intervention on increasing physical activity. We will do so with a purpose-made app, called i2be.
Physical activity interventions
Most people fail to meet international guidelines on physical activity, and interventions designed to change this rarely achieve large and long-term effects. Potential explanations for these hampered effects are the limited theoretical basis, their limited use of evidence-based behaviour change techniques, and their underestimation of the role of automatic processes in determining behaviour.
Theories accounting for both the automatic processes generating impulses (such as stress, affect and habit) and deliberative processes controlling these impulses (such as planning, intention and motivation) that determine behaviour are relatively new, and are called dual-system theories. The present intervention is based on a specific dual-system theory: the integrated behaviour change (IBC) model, first introduced by Hagger and Chatzisarantis in 2014. The IBC model separates deliberative processes into two sub-types, motivational and volitional processes, thereby differentiating between three main types of processes in total. This clear distinction between pre-intentional (motivational) and post-intentional (volitional) processes, as well as accounting for automatic processes, may be key in explaining and bridging the intention-behaviour gap.
The i2be app
i2be stands for both ‘I to be’, as in fulfilling one’s potential (healthy) self; as well as from ‘i to b’, as in from intention to behaviour. Participants will use the i2be app - designed by the digital health company Avegen - in combination with a Fitbit device for the duration of eight weeks. Participants will receive carefully selected behaviour change techniques to target physical activity, as described by the IBC model. The three conditions of the study are as follows: information condition (information provision only), motivation condition (information provision, and motivational processes targeted), and action condition (information provision, and motivational, volitional and automatic processes targeted). To elaborate on just one hypothesized pathway, we expect that mindfulness-based stress reduction activities delivered in-app will decrease stress among the action condition’s participants, which will lead them to be more physically active, ultimately decreasing their risk for CVD. The app will have several gamified elements: participants will accumulate points and receive various prizes for participation.
The main goal of our study is to gain scientific insight into the added value of not only targeting motivational processes (as traditional health behaviour interventions do), but also the volitional and automatic processes that determine physical activity. The size of this added value will be benchmarked against the added value of targeting motivational processes, as compared to providing information only (similarly to usual care), providing practical insight for clinicians. The studied outcomes of this research are Fitbit-measured weekly physical activity, physiological and well-being measures (for example Fitbit-measured resting heart rate), and variables that are hypothesized to underlie the effects of behaviour change techniques (for example stress). Outcomes will be assessed both short-term, and up to 12 months after the intervention.
The population base will consist of women who have experienced a high blood pressure condition during pregnancy. We want to focus on this population for several reasons. Firstly, a physical activity intervention may provide an especially high social return in this population due to their increased risk for CVDs later in life. Secondly, these women are highly motivated to participate in a physical activity intervention, partly due to the ‘window of opportunity’ that their new motherhood presents, and partly due to their elevated risk for CVDs later in life. Thirdly, these women typically do not have any physical limitations that would prevent their participation in a physical activity intervention, as other patient groups with a high CVD risk might have. Fourthly, these women are relatively young and healthy (their elevated risk for CVDs is not likely to manifest until later in life), which may make our findings generalizable to other young and healthy populations.
Digitalization in healthcare
Digitization in healthcare is transforming the way health conditions are prevented, treated and managed. E-health interventions, including app-delivered interventions, are a quickly emerging field of prevention. This is reflected by the increasing number of digital health companies, the need for long-distance healthcare solutions during the COVID-19 pandemic, and investments made by healthcare groups. One of the main goals of the Smarter Choices for Better Health Initiative is to produce cost-effective and scalable healthcare solutions. To name another prominent example, one of the fundamental goals of the Medical Delta convergence – an extensive collaboration between Erasmus Medical Center and other universities, medical centers, universities of applied sciences, governments, companies, healthcare institutions and other parties in the province of Zuid-Holland - is to aid self-management through e-health. I hope that the i2be app will contribute to meeting these goals. The intervention is set to start in September 2021 – stay tuned!
Lili Kókai pursues a PhD at the Department of Public Health at the Erasmus MC. In her research she combines theories, techniques and methodologies of health behaviour change in health psychology and behavioural economics to design, implement and evaluate a randomized e-health intervention. Her main research interests are primary prevention, mental health, and e-health interventions. You can contact her via email: firstname.lastname@example.org.