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Changes in Behavior to Improve Health with Digital Technologies
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By Joan Cornet Prat

How many times does a doctor tell his patient that he has to lose weight, that he has to follow a certain diet or that he has to follow to the letter a certain pharmacological prescription, and the patient continues with his habits, often hides the truth and does not follow what they are prescribed and does not make the changes that would be beneficial.

Without going further, people without obvious pathologies, knowing that smoking or drinking alcohol in excess harms their health, they continue to self-deceive, justifying any reason to continue practicing habits knowing how pernicious all this is.

Health-related behavior is one of the most important elements in the health and well-being of people. Its importance has grown as public health has improved and medicine has advanced. Previously incurable or fatal illnesses can now be prevented or treated successfully, and health-related behavior has become an important component of public health. Improving health-related behaviors is therefore fundamental to public health activities.

Behavioral factors play a role in each of the 12 leading causes of death, including chronic diseases such as heart disease, cancer and stroke, which are the leading causes of death in developed countries. The most common behavioral factors that contribute to mortality or death include the use of alcohol, tobacco, and the irresponsible driving of a vehicle; diet and activity patterns; sexual behavior; and the illicit use of drugs.

A healthy lifestyle includes healthy eating, daily physical activity, reduced sedentary behavior, sun protection, and regular cancer screening tests. In addition to the lifestyle choices you make, health is also determined by the type of environment that you and your family live, work, learn and enjoy, as well as policies that impact your daily life.

Being physically active and minimizing sitting time (sedentary behavior) is an important way to maintain the good health you currently enjoy and reduce the risk of many chronic illnesses.

But why does this paradox, knowing that our habits are harmful to our health, but continue with them?


A clue to better understand this paradox

Homo sapiens, the first modern humans, evolved from their primitive hominid predecessors about 250,000 years ago. They developed a language capacity about 50,000 years ago. Homo sapiens are part of a group called hominids, which were the first human-like creatures. Based on archaeological and anthropological evidence, we believe that hominids were parted from other primates somewhere between 2.5 and 4 million years ago in East and South Africa. Although there was a degree of diversity among the hominid family, they all shared the trait of being bipeds, or the ability to walk upright on two legs. (1)

The problem is that our brain has not evolved as our society has. Based on the previous figures, most of our history as humans has been developed in societies in which hunting and foraging were the most important activity in order to survive. Nothing really changed until about 3000 years ago. If we add that the real changes started about 500 years ago and that have been accelerated for 300 years, we concluded that in 90% of our history, human activity was focused on survival, basically hunting animals, finding fruits and vegetables, defending themselves from wild animals and from enemy tribes. Our brain is practically the same. An example is the need to find sugary foods, that is to look for fruit from our ancestors, to get energy, has become our current time in an abuse of foods prepared with large doses of sugar, causing an epidemic of obesity. Being obese in our distant history, was practically impossible. Humans had to be very agile to get their prey, they had to fight wild beasts, if they did not want to become tasty food for them, and often had to fight with enemy tribes.  In short, to survive it was necessary to have an iron health and an extraordinary physical form.


Behavioral changes in health are possible. As long as there is adequate motivation.

The discovery of knowledge about diseases, technological assessments and pharmacology has broadly exceeded knowledge about how to help people incorporate health care advances into their daily lives (2). Abundant information is available on health promotion, but quality and sources (3). There is relatively little available to help people sort information, much less apply it to their lifestyles. Health professionals need to better understand how changes in health behavior and their role are made to facilitate and support change. How do people change the health behavior that persists in time?

That behavior is critical to people's health is undeniable. The number of people in the world with type 2 diabetes is expected to increase from 366 million today to 552 million in 2030; and considering that about 17 million people died of cardiovascular disease in 2008, some 23 million are expected to do so in 2030. (4) The response and understanding of these epidemics should include human behavior. However, it is not just the individual behavior that drives these epidemics. Behavior takes place in social environments and efforts to change it should consider the social context and political and economic forces that act directly on people's health, regardless of the individual decisions that they can take on their own behavior. (5)

New theories are needed to better understand the change in health behavior. One of them, ITHBC (Integrated Theory of Health behavior change) assumes that behavior change is a dynamic and iterative process. Desire and motivation are prerequisites for change, and reflection facilitates progress. Positive social influences influence one's interest and will as well as positive relationships help support and sustain change. There is increasing evidence that person-centered interventions are more effective than standardized interventions to facilitate behavioral change in health (6) Participation in healthy behavior is a result that can be achieved by short-term (a proximal outcome) and participation in health behavior influences and leads to improvement in health status, the distal outcome performed over time.

Model of Integrated Theory of Health Behavior Change.


The perception of risk, the expectation of results and the self-efficacy of tasks are considered predisposing factors in the phase of goal-setting (motivational phase), while planning, action control and self-efficacy of maintenance/recovery are considered influential in the phase of pursuit of objectives (volition phase). The first phase leads to the formation of an intention, and the second phase leads to a real change of behavior. Such a mediator model serves to explain the social cognitive processes in the change of health behavior. By adding a second layer above, a moderator model is provided which distinguishes three stages to segment the audience for adapted interventions. Identifying people as precursors, intendants, or actors offers the opportunity to relate theory-based treatments to specific target groups.


Digital technologies can be very helpful.

Adherence to chronic disease management is essential for achieving better health outcomes, quality of life, and effective medical care. As the burden of chronic diseases continues to grow globally, so does the impact of non-accession. Mobile technologies are increasingly being used in health care and public Health Practice (mHealth) for communicating, monitoring and educating patients, and for facilitating compliance with chronic disease treatment.

As more behavioral health interventions move from traditional to digital platforms, the application of evidence-based theories and techniques can be doubly advantageous. First, it can accelerate the development of digital health intervention, improve efficiency and increase reach. Second, moving behavioral health interventions to digital platforms present researchers with novel (paradigm-changing) opportunities to advance theories and techniques. In particular, the potential of technology to revolutionize the refinement of theory is possible by leveraging the proliferation of objective measurement in "real time" and "large data" commonly generated and stored by digital platforms. Much more could be done to achieve this potential. The challenge is to take better advantage of the potential benefits of digital health platforms, and to review three of the most advanced methods to do so: Optimization designs, dynamic system modeling, and social network analysis.


Examples of applications for tracking long-lasting behavior change habits describes this application as the most robust habits tracker there is. Basically, every day that completes a task (for example, 10 minutes of meditation) marks a square. So the visual chains are formed. The longer your chain is, the less likely it will break, so the thought remains constant.


Way of life/Lifestyle

This elegant application also allows you to create chains with options to skip days or establish negative habits, which encourage you not to do a certain thing (ie, eating sugar). The simple interface helps you to see your progress over time, to achieve the goals that we make decided to improve our health,




Habitica is a videogame designed to improve your real-life habits that "gamefic" your life, converting all your tasks (habits, daily tasks and earrings) in small monsters that you must overcome. The better you do it, the more you progress in the game. If you don't fulfill something in real life, your character will start to suffer the consequences in the game


Intelligent Pain Diary 

To treat pain effectively, experts recommend that you keep a diary. CatchMyPain helps you express your pain, explain it to others and observe the success of your treatment. In addition to all of this, you can connect with similar patients and support the fight against pain.


Esporti Revolution

It is an app to improve the health of children and adolescents through two keys: physical activity and healthy habits. An excellent tool for families, professionals and organizations that care for the health of the youngest, which also enables tele-monitoring and telemedicine.


Social diabetes

Application of aid to the control of diabetes mellitus type 1 or 2. It allows the patient to keep track of meals, medication and blood glucose levels, offering personalized advice and recommendations, evolution charts, drug database, etc. It also includes the possibility of sharing diets with other users of any part of the world or authorize the health professional to manage and do a remote and real-time monitoring of the disease, allowing to readjust the medication and feeding.


Let's play to change our habits

Gamification is defined as the use of game design elements in non-game contexts. The idea is that if we can isolate the active ingredients that make the games addictive, intervention developers can put those ingredients into their digital technologies and make them addictive as well. For example, we can do a routine activity that is not a game, like taking medications, in a game that is fun and engaging adding game elements, like earning points for taking medications.

Mango Health has developed a smart phone application designed to motivate patients to take their medications on time. Users set the hours on which medications should be taken and the application remembers them. It also provides information about drugs and warns about drug interactions and side effects. By taking the medications properly, users earn points for gift cards or charitable donations in weekly raffles.



MindMaze has created devices that use virtual reality, brain imaging, and gaming technologies to recycle the brain of stroke victims. It also works in solutions for spinal cord injuries and amputee patients.



By way of conclusion

Programs and devices that use digital technology (digital interventions) have great potential to improve the health of the population and the efficiency and scope of the provision of health services. Mobile applications, SMS messages (short message service), portable and environmental sensors, social networks and interactive websites can improve health by supporting behaviors related to disease prevention, self-control of long-term conditions and the provision of health services based on clinical evidence. These interventions also have the potential to cause harm if they provide inadequate counseling, involve interactions that undermine desired behaviors, share data inappropriately, or are used instead of change-over interventions more effective behavior.

Many of these digital interventions seek to encourage or support behavior change by health professionals, patients, or the general public. The challenges involved in the development, evaluation and implementation of effective digital behavior change interventions, and the prevention of the use of counterproductive methods, have scarcely begun to delineate, and even less to be fulfilled. Some of the challenges are like those faced by other behavior-change interventions, but many are unique, including developmental rates, commitment to intervention, measurement of effectiveness and profitability, and compliance with regulatory, ethical and security requirements.



(1) Strayer, Robert W. and Eric W. Nelson, _Ways of the World: a Global History (New York: Bedford/St. Martin's, 2016), 3-4

(2)Institute of Medicine . Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences: Committee on Health and Behavior: Research, Practice and Policy Board on Neuroscience and Behavioral Health. National Academy Press; Washington, DC: 2001.

(3) US Department of Health and Human Services Office of Disease Prevention and Health Promotion (ODPHP) Improved makes health information quicker and easier to use: DHHS. 2008. [September 22, 2008].

(4) L. Chen, D.J. Magliano, P.Z. Zimmet. The worldwide epidemiology of type 2 diabetes mellitus – present and future perspectives. Nat Rev Endocrinol, 8 (2012), pp. 228-236

(5) L.J. Laslett, P. Alagona, B.A. Clark, J.P. Drozda, S.R. Wilson, C. Poe, et al.The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issuesJ Am Coll Cardiol, 60 (Suppl. 25) (2012)

(6) Development of a framework for person-centred nursing. McCormack B, McCance TVJ Adv Nurs. 2006 Dec; 56(5):472-9.